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MINOR SURGERY 



BANDAGING 



INCLUDING 



THE TREATMENT OF FRACTURES AND DISLOCATIONS, THE 
LIGATION OF ARTERIES, AMPUTATIONS, EXCISIONS 
AND RESECTIONS, OPERATIONS UPON NERVES 
AND TENDONS, TRACHEOTOMY, INTUBA- 
TION OF THE LARYNX, ETC. 

BY 

HENRY R. WHARTON, M.D., 

DEMONSTRATOR OF SURGEBY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE 

PRESBYTERIAN HOSPITAL, THE METHODIST EPISCOPAL HOSPITAL, AND 

THE CHILDREN'S HOSPITAL | CONSULTING SUBGEON TO 

THE PBESBYTEEIAN OBPHANAGE. 



THIRD EDITION, THOROUGHLY REVISED AND ENLARGED, 
"WITH 475 ILLUSTRATIONS. 




IIIN 



v\*' 



LEA BROTHERS & CO., 

PHILADELPHIA AND NEW YORK. 
1896. 



Entered according to the Act of Congress, in the year 1896, by 

LEA BKOTHEHS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTER. 



PREFACE TO THIRD EDITION. 



In the preparation of the third edition of this work 
the subject-matter has been carefully revised and certain 
additions have been made. From the fact that much 
attention is now paid in our medical schools to operative 
work upon the cadaver, it has seemed advisable to the 
author to add a considerable amount of new material 
upon the subjects of excision of the joints, operations 
upon nerves, tendons, etc. The descriptions of these 
operative procedures are brief and are not intended to 
take the place of the more varied and elaborate descrip- 
tions given in works upon operative surgery, but have 
been introduced to add to the value of the work as a 
handbook for students in their operative work upon the 
cadaver. The author's thanks are due to Dr. Joseph P. 
Tunis for kind assistance in revising the proof-sheets. ' 

1725 Spruce St., Philadelphia, January, 1896. 



PREFACE TO SECOND EDITION. 



The author has been much gratified at the favorable 
reception which has been accorded to this work, and has 
endeavored in the preparation of a second edition to make 
it more worthy of a continuance of that favor. The 
aseptic and antiseptic methods of wound treatment have 
been thoroughly revised, and a considerable amount of 
new matter, with a number of new illustrations, have 
been added. The author's thanks are due to Dr. Joseph 
P. Tunis for his kind assistance in revising the proof- 
sheets. 

112 South Eighteenth St., Philadelphia, July, 1893. 



PREFACE TO FIRST EDITION. 



The author has, in this work, endeavored to present, 
in as concise a manner as possible, a description of the 
various bandages, surgical dressings, and minor surgical 
procedures which are employed in the practice of surgery 
at the present time. The preparation and application of 
the antiseptic dressings now most commonly used have 
also received full consideration. The article upon Ban- 
daging is fully illustrated with cuts, mostly new and 
taken from photographs, which, it is hoped, will prove of 
value as furnishing an accurate representation of the most 
important bandages used in surgical practice ; the same 
is in a measure true of the article upon the dressing of 
Fractures and Dislocations, in which many new cuts of 
the same kind appear. 

The work also contains short articles upon Tracheot- 
omy, Intubation of the Larynx, the Ligation of Arteries, 
and Amputations, and, although these procedures are 
scarcely to be included with those of Minor Surgery, it 
is hoped that their description will increase the value 
of the work to medical students, for whose use it has 



viii PREFACE. 

been prepared. The author's thanks are due to Dr. 
Walter D. Green for his kind assistance in revising the 
proof-sheets, and to Mr. James Wood for the skilful 
photographic work used in illustrating several of the 
articles. 

112 South Eighteenth St., Philadelphia, August, 1891. 



CONTENTS. 



PART I. 
BANDAGING. 

Varieties of Bandages 
Bandages for the Head and Neck 
Bandages of the Upper Extremity 
Bandages of the Trunk . 
Bandages of the Lower Extremity- 
Special Bandages 
Fixed Dressings or Hardening Bandages 



PAGES 

13-41 

41-57 

57-75 

75-80 

80-93 

93-100 

100-118 



PART II. 

MINOR SURGERY. 

Theory of Asepsis and Antisepsis in Wound Treatment 119-124 

Agents Employed to Secure Asepsis .... 124-132 
Preparation of Materials Used in Aseptic Surgery and 

Dressings 132-140 

Preparation of Gauze Dressings 140-145 

Methods and Dressings Employed in the Treatment of 

Wounds to Secure Asepsis 145-146 

Preparation for Aseptic Operation and Dressing of 

Wounds 146-158 

Materials Used in Surgical Dressings .... 158-166 

Procedures Employed in Minor Surgery . . . 166-229 

Anaesthetics 229-241 

Trusses 241-245 



x CONTENTS. 

PAGES 

Use of Catheters and Bougies 245-254 

Sutures 254-274 

Ligatures Used in the Treatment of Vascular Growths 274-280 

Treatment of Hemorrhage .... . . 280-304 

Opening and Dressing of Abscesses .... 304-307 

Dressing of Wounds, Burns and Scalds, Bedsores, 

Sprains 307-317 



PART III. 

FRACTURES. 

General Consideration of Fractures .... 318-331 
Treatment of Special Fractures . . . . . 331-392 



PART IV. 

DISLOCATIONS. 

General Consideration of Dislocations .... 393-395 
Special Dislocations 395-423 



PART V. 

OPERATIONS. 

Ligation of Arteries 424-426 

Ligation of Special Arteries . . . ... 427-458 



PART VI. 

AMPUTATIONS. 

General Consideration of Amputations .... 459-472 
Special Amputations 473-515 



CONTENTS. xi 

PART VII. 
EXCISIONS AND RESECTIONS. 

PAGES 

General Consideration of Excisions and Resections . 516-519 
Special Excisions and Resections 519-537 



Trephining 538-540 

Operations upon Nerves 540-546 

Operations upon Tendons ...... 547-552 

Tracheotomy . 553-562 

Laryngotomy 562-563 

Laryngo-tracheotorny 563-564 

Intubation of the Larynx 564-569 

Operations upon the Kidney ...... 570-571 

Operations upon the Colon . . . . . . 571-572 

Lithotomy 572-574 

Special Operations 574-577 

Osteotomy . . 577-579 

Index 580 



PART I. 

BANDAGING 



Bandages constitute one of the most widely used and 
important surgical dressings ; they are employed to hold 
dressings in contact with the surface of the body, to make 
pressure, to hold splints in place in the treatment of frac- 
tures and dislocations, and to restore to their natural posi- 
tion parts which may have become displaced. 

Bandages may be prepared of various materials, such as 
linen, crinoline, flannel, cheese- or tobacco-cloth, rubber- 
sheeting, or muslin, bleached or unbleached; the latter ma- 
terial is the most commonly employed, by reason of the ease 
with which it is obtained and its cheapness ; flannel, from 
its elasticity, is sometimes used, but its employment for 
bandages is now generally limited to its use in dressings 
for operative w r ork in connection with the eye, and for a 
primary roller in the application of the plaster-of-Paris 
dressings. 

Bandages are either simple, when composed of one piece 
of material, such as the ordinary roller-bandage, or com- 
pound, when prepared of one or more pieces, adapted by 
size and shape to peculiar objects. 

Bandages are also described as uniting, dividing, com- 
pressing, expelling, or retaining bandages, according to the 
purposes they serve by their application. 

The importance of being perfectly familiar with the gen- 
eral rules of bandaging and proficient in the application of 
the roller-bandage cannot be overestimated, and both the 
student and general practitioner will never have cause to 

2 



14 BANDAGING. 

regret the time occupied in learning to apply neatly this 
form of surgical dressing. 

A well-applied bandage adds to the comfort of the pa- 
tient, and the method of its application often secures for 
the physician the confidence both of the patient and of his 
friends, while, on the other hand, a badly applied bandage 
is apt to be uncomfortable and insecure, and to meet with 
their adverse criticism. 

The Roller-bandage. 

The roller-bandage consists of a strip of woven material, 
prepared from some of the materials previously mentioned, 
of variable length and width according to the portion of 
the body to which it is to be applied ; this, for ease of 
application, is rolled into a cylindrical form. 

Fig. 1. 




Bandage-winder. 



The material commonly employed for the roller-bandage 
is unbleached muslin, although, for special purposes, linen, 
flannel, rubber-sheeting, crinoline or cheese-cloth may be 
used. It is important that the roller-bandage should con- 
sist of one piece, free from seams and selvage, for if made 
of a number of pieces sewed together, or if it contains 



THE B OLLER-BANDA GE. \ 5 

creases or selvage, it cannot be so neatly applied, and it is 
not so comfortable to the patient, as it is apt to leave 
creases upon the skin. 

In preparing the ordinary muslin-bandage the material 
is torn in strips varying in length and width according to 
the part of the body to which it is to be applied, and it is 
then rolled into a cylinder, either by the hand or by a 
machine constructed for the purpose. (Fig. 1.) 

It is important that every student and practitioner 
should be able to roll a bandage by hand, for in practice 
the medical attendant may at any moment be called upon 

Fig. 2. 




Rolling a bandage "by hand. 

to roll a bandage, in order to apply a dressing, and as the 
art of preparing a bandage is acquired by a little practice, 
it should be familiar to every student and physician. To 
roll a bandage by hand the strip should be folded at one 
extremity several times until a small cylinder is formed ; 
this is then grasped by its extremities by the thumb and 
index-finger of the left hand ; the free extremity of the 
strip is then grasped between the thumb and index-finger 
of the right hand, and by alternate pronation and supina- 
tion of the right hand the cylinder is revolved and the 
roller is formed ; the firmness of the roller will depend 



16 



BANDAGING. 



upon the amount of tension which is kept upon the free 
extremity of the strip during the revolution of the cylin- 
der. (Fig. 2.) 



Fig. 3. 




Single roller. 



A bandage rolled in the form of a cylinder is called a 
single or sinc/le-headed roller (Fig. 3) ; if rolled from each 
extremity toward the centre so that two cylinders are 



Fig. 4. 




Double roller. 



formed joined by the central portion of the strip, the 
double or double-headed roller is formed. (Fig. 4.) Double 
rollers are not much used, and in practice the single roller 



GENERAL RULES FOR BANDAGING. 17 

will be found to be amply sufficient for the application of 
almost all the bandages employed in surgical dressings. 

The free end of the roller-bandage is called the initial 
extremity ; the end which is enclosed in the centre of the 
cylinder is its terminal extremity ; and the portion between 
the extremities the body ; a roller has also two surfaces, 
external and internal. 

Dimensions of Bandages. 

Bandages vary in length and width according to the pur- 
poses for which they are employed, and in practice it will 
be found that a small variety of bandages will be amply 
sufficient for the application of the ordinary surgical 
dressings. 

The following list comprises those most frequently used 
and will show their dimensions : 

Bandage one inch wide, three yards in length, for ban- 
dages for the hand, fingers, and toes. 

Bandage two inches wide, six yards in length, for head- 
bandages and far the extremities in children. 

Bandage two and a half inches wide, seven yards in 
length, for bandages of the extremities in adults ; a roller 
of this size is the one most generally used. 

Bandage three inches wide, nine yards in length, for 
bandages of the thigh, groin, and trunk. 

Bandage four inches wide, ten yards in length, for ban- 
dages of the trunk. 

General Rules for Bandaging. 

In applying a roller-bandage the operator should place 
the external surface of the free extremity of the roller upon 
the part, holding it in position with the fingers of the left 
hand until fixed by a few turns of the roller, the cylinder 
being held in the right hand by the thumb and fingers ; 
for thus as the bandage is unwound it rolls into the oper- 
ator's hand, thereby giving him more control of it ; care 



]{ 



BANDAGING. 



should also be taken that the turns are applied smoothly 
to the surface, and that the pressure exerted by each turn 
is uniform. 

When a bandage is applied to a limb the surgeon 
should see that the part is in the position it is to occupy 
as regards flexion and extension when the dressing is com- 
pleted, for a bandage applied when the limb is flexed will 
exert too much pressure when the limb is extended, and 
then may, by the pressure it exerts, become a matter of 
discomfort or even of danger to the patient, or if applied 
to an extended limb it will become uncomfortable upon 
flexion. 

Fig. 5. 




Method of removing a bandage. 



My experience has been that, as a rule, those who have 
had little experience with the application of the roller- 
bandage are apt to apply their bandages too tightly, and 
this may lead to disastrous consequences, especially in the 
dressing of fractures. Professor Ashhurst, in his clinical 
teaching, advises students to make use of a larger number 



VARIETIES OF BANDAGES. 19 

of turns of a bandage in securing fracture-dressings rather 
than to depend upon a few turns too firmly applied ; advice 
which certainly conduces to the safety and comfort of the 
patient. When the bandage has been completed the ter- 
minal extremity should be secured by a pin or safety-pin 
applied transversely to the bandage, and if a pin be used 
its point should be buried in the folds of the bandage ; if 

Fig. 6. 




Bandage-scissors. 

the bandage be a narrow one, the end may be split and 
the two tails resulting may be secured around the part by 
tying. In removing a bandage the folds should be care- 
fully gathered up in a loose mass as the bandage is 
unwound, the mass being transferred rapidly from one 
hand to the other, thus facilitating its removal and pre- 
venting the part from becoming entangled in its loops. 
(Fig. 5.) If it is desirable to cut the bandage to remove 
it, the use of scissors made for this purpose will be found 
most satisfactory. (Fig. 6.) 



Varieties of Bandages. 

The Circular Bandage. 

This bandage consists of a few circular turns around a 
part, each turn covering accurately the preceding turn. 
This variety of bandage may be used to retain a dressing 
to a limited portion of the head, neck, or limbs, to make 



20 



BANDAGING. 



compression upon the veins of the arm before performing 
venesection. (Fig. 11, b.) 

The Oblique Bandage. 

In this form of bandage the turns are carried obliquely 
over the part, leaving uncovered spaces between the suc- 

Fig. 7. 




Oblique bandage. 

cessive turns. (Fig. 7.) Its principal use is for the 
application of temporary dressings. 

The Spiral Bandage. 

In this bandage the turns are carried around the part 
in a spiral direction, each turn overlapping a portion of the 

Fig. 8. 




Ascending spiral bandage. 



preceding one, usually one-third or one-half; it may be 
applied as an ascending spiral (Fig. 8) or as a descending 



VARIETIES OF BANDAGES. 21 

spiral (Fig. 9). This bandage may be used to cover a 
part which does not increase too rapidly in diameter ; for 
instance, the abdomen, chest, or arm. 

Fig. 9. 




Descending spiral bandage. 

The Spiral Reversed Bandage. 

This bandage is a spiral bandage, but differs from the 
ordinary spiral bandage in having its turns folded back or 
reversed as it ascends a part, the diameter of which gradu- 
ally increases. By its use it is possible to cover by spiral 
turns a part conical in shape, so as to make equable 
pressure upon all parts of the surface. The reverses are 
made as follows : After fixing the initial extremity of the 
roller, as the part increases in diameter the bandage is 
carried off a little obliquely to the axis of the limb for 
from four to six inches ; the index-finger or thumb of the 
disengaged hand is placed upon the body of the bandage 
to keep it securely in place upon the limb, the hand hold- 
ing the roller is carried a little toward the limb to slacken 
the unwound portion of the bandage, and by changing the 
position of the hand holding the bandage from extreme 
supination to pronation the reverse is made. (Fig. 10.) 
Care should be taken not to attempt to make the reverse 
while the bandage is tense, for by so doing the bandage is 
twisted into a cord which is unsightly and uncomfortable 
to the patient, instead of forming a closely fitting reverse. 

2* 



22 BANDAGING. 

The reverse should be completed before the bandage is 
carried around the limb, and when it has been completed 
the bandage may be slightly tightened so as to conform to 
the part accurately. 

Fig. 10. 




Method of making reverses. 

The reverses should be in line to have the bandage 
present a good appearance, and care should be taken that 
the reverses should not be made over salient parts of the 
skeleton, for if they occupy such positions they cause 
creases in the skin and become uncomfortable to the 
patient. 

To make reverses neatly and to have them in line 
require skill and practice ; a well-applied spiral reversed 
bandage is a test of a competent bandager. 

Spiea-bandage. 

When the turns of the roller cross each other in the 
form of the Greek letter lambda, leaving the previous turn 
about one-third uncovered, the bandage is known as a 
spica -bandage. (Fig. 11, a.) These spica-bandages are 
especially serviceable as a means of retaining surgical 



VARIETIES OF BANDAGES. 



23 



dressings upon particular portions of the surface of the 
body, such as the shoulder, groin, or foot. 



Fig. ll. 




Spica-bandage. 



Circular bandage. 



Figure-of-eight Bandage. 

This bandage receives its name from the turns being 
applied so as to form a figure-of-eight. This method of 

Fig. 12. 




Recurrent bandage. 



application is made use of in the Barton's bandage, the 
bandages of the knee and elbow, and many other bandages. 



24 



BANDAGING. 



Recurrent Bandage. 

This bandage derives its name from the fact that the 
roller after covering a certain part of the surface is re- 
flected and brought back to the point of starting ; it is 
then reversed and carried toward the opposite point, and 
this manipulation is continued until the part is covered 
by these recurrent turns, which are then secured by a few 
circular turns. (Fig. 12.) This is the bandage usually 
employed in the dressing of stumps. 

Compound Bandages. 

These bandages are usually formed of several pieces of 
muslin or other material, sewed or pinned together, and 
are employed to fulfil some special indication in the appli- 
cation of dressings to particular parts of the body. The 
most useful of the compound bandages are the T-bandages 
and the many-tailed bandages. 

T-bandage. 

The single T-bandage consists of a horizontal band to 
which is attached, about its middle, another having a ver- 

Fig. 13. 




Single T-bandage. 



tical direction ; the horizontal piece should be about twice 
the length of the vertical piece. (Fig. 13.) The single 



COMPOUND BANDAGES. 



25 



T-bandage may be used to retain dressings to the head, 
the horizontal piece being passed around the head from the 
occiput to the forehead, the vertical piece being passed over 
the head and secured to the horizontal piece, the shape 
and width of the two pieces being varied according to the 
indications. In applying dressings to the anal region or 
perineum, or in securing a catheter in a perineal wound, 
the single T-bandage will be found most useful. In 
applying a T-bandage for this purpose the body of the 
bandage is placed over the spine, just above the pelvis, and 
the horizontal portion is tied around the abdomen. The 
free extremity is split into two tails for about two-thirds 



Fig. 14. 




Single T-bandage for chest. 

of its length, and is carried over the anal region and 
brought up between the thighs, the terminal strips passing 
one on each side of the scrotum and being secured to the 
horizontal strip in front. The single T-bandage may be 
variously modified according to the indications which are 
to be met; for instance, in applying a dressing to the 
breasts the horizontal strip passing around the chest may 
be made ten or twelve inches in width, the vertical strip, 
two inches in width, passes from the back over the shoulder 
and is secured to the horizontal strip in front. (Fig. 14.) 
The single T-bandage may be variously modified, according 
to the ideas of the surgeon, so as to meet the indications 



26 



BANDAGING. 



presented in special cases. For the groin a piece of 
muslin six inches wide at its base and thirty inches long 
is sewed to a horizontal strip of muslin one and a half 



Fig. 15. 




T-baudage oi groin. 

yards long and two inches in width. It may be applied 
as in Fig. 15 to hold a dressing to this part. 

Double T-bandage. 

The double T-bandage differs from the single bandage 
in having two vertical strips attached to the horizontal 
strip and it may be used for much the same purposes as 
the single T-bandage. (Fig. 16.) It may be conveniently 
used for retaining dressings to the chest, breasts, or abdo- 
men ; when used for this purpose the horizontal portion 
should be from eight to twelve inches wide and long 
enough to pass one and a quarter times about the chest ; 
two vertical strips, two inches wide and twenty inches 
long, should be attached to the horizontal strip a short 



COMPOUND BANDAGES. 



27 



distance apart near its middle. In applying this bandage 
to the chest, the horizontal strip is placed around the chest 
so that the vertical strips occupy a position on either side 



Fig. 16. 




Double T-bandage. 



of the spine ; the overlapping end of the horizontal portion 
is secured by pins or safety-pins, and the vertical strips 



Fig. 17 



Fig. 18. 





Double T-bandage of chest. 



Double T-bandage of nose. 



are next carried one over either shoulder and secured to 
the other portion of the bandage in front of the chest. 
(Fig. 17.) 



28 



BANDAGING. 



The double T-bandage may also be used to secure dress- 
ings to the nose, in which event the strips should be quite 
narrow, about one inch in width, and should be applied 
as shown in Fig. 18. 

Many-tailed Bandages or Slings. 

These bandages are prepared from pieces of muslin of 
various lengths and breadths, which are split at each ex- 
tremity into two, three, or more tails up to within a few 
inches of their centres, their width and length being regu- 
lated by the part of the body to which they are to be 
applied. 



Fig. 19. 



Fig. 20. 





Four-tailed bandage of chin. 



Four-tailed bandage of head. 



The four-tailed bandage may be found useful as a tem- 
porary dressing in cases of fracture of the jaw, or to hold 
dressings to the chin. It may be prepared by taking a 
portion of a roller-bandage three inches wide and one yard 
in length, and splitting each extremity up to within two 
inches of the centre ; it is then applied as seen in Fig. 1 9. 

The four-tailed bandage may also be used to retain 
dressings to the scalp, and can be prepared by taking a 



HANDKERCHIEF-BANDAGES. 29 

piece of muslin one yard and a quarter long and six or 
eight inches in width, splitting it at each extremity into 
two tails within six inches of the centre ; it may then be 
applied as seen in Fig. 20. 

The four-tailed bandage may also be used in the tem- 
porary dressing of fractures of the clavicle — the body of 
the bandage being placed upon the elbow of the injured 
side, two tails passing around the body, fixing the arm to 
the side, and two tails passing over the sound shoulder. 

The many-tailed bandage may also be used for holding 
dressings in contact with the abdomen or trunk, and is the 
bandage which many surgeons employ to hold the dressings 
to a laparotomy-wound, and to give support to the abdom- 
inal walls after this operation. In preparing this bandage, 
a strip of muslin or flannel, one and a half yards in length 
and eighteen to twenty inches in w r idth, is required : the 
extremities may be split so as to form an eight-tailed ban- 
dage. In applying this bandage to the abdomen, the body 
is placed upon the patient's back and the tails are brought 
around the abdomen and overlap each other, and when 
sufficiently firmly drawn to make the desired amount of 
pressure they are secured by means of safety-pins. 



Haxdkeechief-baxdages. 

The use of handkerchiefs or square pieces of muslin for 
the temporary or permanent dressing of wounds, fractures, 
or dislocations was advocated many years ago by M. Mayor, 
a Swiss surgeon, who wrote an extensive work upon this 
subject, in which he reduced their application to a system. 
He employed a handkerchief or a square piece of muslin, 
and by various modifications in the application of these 
developed a number of very ingenious bandages. 

The various forms which the handkerchief or square 
(Fig. 21) is made to assume are as follows : The oblong, 
made by folding the square once or twice on itself (Fig. 
22). The triangle, made by bringing together the diagonal 
angles of the square (Fig. 23). The line of folding is 



30 



BANDAGING. 



known as the base, the angle opposite the base the apex, 
and the other angles the extremities 

The cravat is prepared from the triangle by bringing 
the apex to its base, and folding it a number of times 
upon itself until the desired width is obtained. (Fig. 24.) 



Fig. 21. 



Fig. 22. 



-=k 


1 J 

f-~=r:r-"j 
f>..- \ 

|| ™==J 

ill i 


J J 1 


t 


ii - -'-'-'■- 


ill! a 






i 

ill: --- i 


1! 


i 

"if----- 


:.;:—:==.:..- ■ ■ 


J:3f!=^ 




Thesq 


uare. 




The oblong. 



Fig. 23. 




The triangle. 

The cord is formed from the cravat twisted upon itself. 
(Fig. 25.) The names of the various handkerchief-ban- 
dages are derived from the shape of the handkerchiefs 
used and the parts to which they are applied ; the names 
serve as guides in their application. It is to be remem- 
bered that the base of the triangle or the body of the 
cravat is to be placed upon the portion, the designation of 



HANDKEECHIEF-BANDA GES. 



31 



which forms the first portion of the Dame of the bandage; 
thus, in the occipitofrontal triangle, the shape of the hand- 



FlG. 24. 



The cravat. 
Fig. 25. 



The cord. 



kerchief is given, and we know that the base of the 
triangle is to be applied to the occiput and then pass to 



Fig. 26. 




Occipi to -frontal triangle. 



the forehead. In using the cravats the same rule applies ; 
thus, in the bis-axillary cravat the body of the cravat is 
to be placed in the axilla of the aifected side, the extremi- 



32 BANDAGING. 

ties crossed over the corresponding shoulder and carried 
over the chest, one before, the other behind, to the axilla 
of the opposite side, where they are secured. 

The Occipitofrontal Triangle. 

To apply this handkerchief place the base of the tri- 
angle upon or a little below the occiput, and bring the 
apex forward over the head, allowing it to drop over the 
forehead ; next bring the extremities of the handkerchief 
forward and tie them in a knot over the forehead ; finally 
turn up the apex over the knotted ends and pin to the 
body of the handkerchief. (Fig. 26.) 

The Mento-vertico-occipital Cravat. 

Fig. 27. 




Meuto-vertico-occipital cravat. 



To apply this handkerchief the middle of the base of 
the cravat is placed under the chin, the extremities are 



HANDKERCHIEF-BANDA GES. 



33 



then carried in front of the ear on each side to the vertex 
of the skull, and are crossed at that point ; the ends are 
then carried downward over the parietal region to the 
occiput and are secured by a knot at this point. (Fig. 
27.) Another method of applying this handkerchief con- 



Fig. 28. 




Mento-vertico cravat (modified). 



sists in placing the base of the cravat under the chin and 
carrying the extremities over the vertex of the skull, 
crossing them at that point, then carrying them down- 
ward to the occiput, and crossing them again here and 



34 



BANDAGING. 



passing them forward around the chin, and finally securing 
the ends by a knot. (Fig. 28.) The turns of the latter 
handkerchief correspond exactly to the turns of the 
Barton bandage of the head. 

These handkerchief- bandages may be used to secure 
dressings to the chin or scalp, or may be employed as 
temporary dressings to secure fixation of the parts in 
cases of fracture or dislocation of the jaw. 

The Bis-axillary Cravat. 

Fig. 29. 




Bis-axillary cravat, 



To apply this handkerchief the body of the cravat is 
placed in the axilla, and the ends are brought up, one in 
front, the other behind the axilla, and are made to cross 



HANDKERCHIEF-BANDA GES. 



35 



over the top of the shoulder; the extremities are then 
carried across the back and chest respectively to the 
opposite axilla, when they are secured by tying. (Fig. 
29.) This handkerchief may be employed to secure dress- 
ings in the axilla, or to hold dressings in contact with 
the shoulder. 

The Dor so-axillary Cravat. 

This handkerchief is applied by placing the body of 
the cravat over the spine between the scapulae, and then 
carrying one extremity over the shoulder and through the 



Fig. 




Dorso-axillary cravat. 



axilla backward to meet the other extremity, which has 
been carried through the axilla and over the other shoulder 
to the back, when the ends are secured by a knot. (Fig. 
30.) This handkerchief may be used to hold dressings 
to the axilla or upper portion of the back of the chest. 



36 BANDAGING. 



The Compound Dorso-bis-axillary Cravat. 

To apply this handkerchief two cravats are required. 
The base of one cravat is placed over the front of one 
shoulder, and the ends are passed, one over the top of the 
shoulder, the other through the axilla, and they are then 
secured by a single knot over the scapula ; the ends are 
next secured by tying them in a loop. The second cravat 
is next placed in front of the shoulder on the opposite 

Fig. 31. 




Compound dorso-bis-axillary cravat. 

side, and the ends are respectively carried over the shoul- 
der and through the axilla to the back, where they are 
secured by a single knot; the ends of the handkerchief 
are then passed through the loop of the other handker- 
chief and secured by a knot. (Fig. 31.) This handker- 
chief may be used to draw the shoulders backward in 
cases of dislocation or fracture of the clavicle. 



HANDKERCHIEF-BANDAGES. 37 

Triangular Cap or Suspensory of the Breast 

To apply this handkerchief the base of the triangle is 
placed under the affected breast, and one extremity is car- 
ried beneath the axilla of the same side, and the other 
extremity is carried around the opposite side of the neck. 

Fig. 32. 




tiff 



Triangular cap or suspensory of the breast. 

and they are secured together upon the back by a knot ; 
the apex should then be brought up over the breast and 
shoulder of the affected side and pinned to the bandage 
over the scapula. (Fig. 32.) This handkerchief may be 
employed to sling the breast in nursing- women, or to hold 
a dressing to the breast. 



38 



BANDAGING. 



The Gluteo-femoral Triangle. 

In applying this handkerchief a cravat is first fastened 
around the waist, and a second handkerchief folded into a 
triangle has its base placed in the gluteo-femoral fold, 
and its extremities are carried around the thigh and 
secured in front by a knot ; the apex of the handkerchief 

Fig 33. 




Gluteo-femoral triangle. 

is then carried upward and passed beneath the cravat 
around the waist, and is turned down and pinned to the 
body of the triangle. (Fig. 33.) This handkerchief may 
be used to retain dressings to the region of the buttock or 
hip ; by unpinning the apex and turning it downward 
ready access can be had to the parts beneath. 

Gluteo-inguinal Cravat. 

In applying this handkerchief the base of the cravat 
is placed just over the gluteo-femoral fold, and the ex- 



HANDKEECHIEF-BANDA GES. 



39 



tremities are carried forward, one around the inner, the 
other around the outer portion of the thigh, and they 
are made to cross in the groin ; the ends are next passed 
around the pelvis and secured together upon the back by 
a knot. (Fig. 34.) This handkerchief may be employed 
to hold dressings to the region of the groin. 

By employing two cravats a double gluteo-inguinal 
cravat may be applied, w r hich may be used to hold dress- 
ings to both groins. The turns of these cravats corre- 
spond to the turns of the single and double spica-bandages 
of the groin. 

Fig. 34. 




Gluteo-iD^uinal cravat. 



I have described a few of the many very ingenious ban- 
dages devised by Mayor to substitute the use of the roller- 
bandage, which will give the student some idea of their 
design and application. It is well to bear in mind this 
system of dressing, for the occasion might occur in which 
the ordinary means of bandaging could not be obtained, 
and the use of handkerchiefs might answer a useful purpose 
as temporary dressings. I think their principal use is for 
temporary dressings, and I do not think they will ever 
take the place of the roller-bandage, which can be applied 
with much greater nicety and exactness, and certainly 
presents a much neater appearance. 



40 



BANDAGING. 



Barton' *s Handkerchief. 

This dressing may be employed to make extension in 
cases of fracture of the leg or thigh. It is applied by 
taking a handkerchief folded into a narrow cravat and 
placing the body of it on the extremity of the os calcis 
below the insertion of the tendo Aehillis, so that two-thirds 
of the cravat comes around under the outer malleolus, and 
the other third remains on the inside. The inside portion 



Fig. 35. 




Barton's handkerchief. 

remaining parallel with the sole of the foot, the outside 
piece is carried over the instep and passed around it so as 
to form a knot, and also passed under the sole of the foot 
to be turned around the first turn and to form another 
knot at the metatarsal articulation, when both ends are 
carried off perpendicularly from the foot. 



BARTON'S BANDAGE. 



41 



REGIONAL BANDAGING. 

Bandages for the Head and Neck. 

Barton's Bandage. 

Roller Two Inches in Width, Six Yards in Length. 

Application.— The initial extremity of the roller 
should be placed on the head just behind the mastoid pro- 
cess, and the bandage should then be carried under the 

Fig. 36. 




Barton's bandage. 



occipital protuberance obliquely upward under and in 
front of the parietal eminence across the vertex of the 
skull, then downward over the zygomatic arch, under the 



42 BANDAGING. 

chin, thence upward over the opposite zygomatic arch and 
over the top of the head, crossing the first turn, which 
was made as nearly as possible in the median line of the 
skull, carrying the turns of the roller under the parietal 
eminence to the point of commencement. The bandage 
is then passed obliquely around under the occipital pro- 
tuberance and forward under the ear to the front of the 
chin, thence back to the point from which the roller started. 

Fig. 37 




Barton's bandage, showing crossing of turns at vertex. 

These figure-of-eight turns over the head and the circular 
turns from the occiput to the chin should be repeated, each 
turn exactly overlapping the preceding one until the ban- 
dage is exhausted. (Fig. 36.) The extremity should then 
be secured by a pin ; and pins should be introduced at the 
points where the turns cross each other to give additional 
fixation to the bandage. In applying the bandage care 
should be taken to see that the turns overlap each other 
exactly, and that the turns passing over the vertex cross 
as near as possible in the median line of the skull. (Fig. 37.) 



MODIFIED BARTON'S BANDAGE. 43 



Modified Barton's Bandage. 

To obtain additional security in the application of the 
Barton's bandage a turn of the bandage passing from the 
occiput to the forehead may be made, this turn being in- 
terposed between the turns of the bandage as ordinarily 
applied. (Fig. 38.) In applying this bandage after the 
first set of turns has been completed, that is, after the 
bandage has been brought back to the occiput, the bandage 

Fig. 38. 



J* 



^90 




Modified Barton's bandage. 

is carried forward upon the head just over the ear, around 
the forehead and backward above the ear on the opposite 
side to the occiput ; this being done, the ordinary figure- 
of-eight and circular turns are made, and when these have 
been completed another occipitofrontal turn may be made 
as described above, and this may be repeated as often as is 
desired until the bandage is exhausted, when the extremity 



44 BANDAGING. 

is fastened with a pin, and pins are also introduced at all 
points at which the turns cross. 

Use. — This bandage is one of the most useful of the 
bandages of the head, being employed to secure fixation 
of the jaw in cases of fracture or dislocation, and for the 
application of dressings to the chin. I have also employed 
it in place of the head-gear in slinging patients for the 
application of the plaster-of-Paris bandage in cases of 
disease of the spine, a stout cord or a piece of bandage 
about three inches wide and one yard long being passed 
under the turns crossing over the vertex ; this cord is then 
secured to the cross-bar of the extension apparatus ; this 
will be found quite as comfortable to the patient as the 
ordinary head-gear employed and much less likely to slip 
out of place and interfere with the breathing of the patient. 

A firmly applied Barton's bandage holds the jaws so 
closely together that care should be taken in applying it 
to patients who are under the influence of an anaesthetic, 
for if vomiting occurs the material may not be able to 
escape from the mouth and suffocation might occur unless 
the bandage were promptly removed. This accident I once 
saw occur, and the patient's condition was alarming until 
the bandage was cut, allowing the jaw to be opened and 
the contents of the mouth to escape. 



Gibson's Bandage. 

Boiler Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller 
should be placed upon the vertex of the skull in a line 
with the anterior portion of the ear ; the bandage is then 
carried downward in front of the ear to the chin, and 
passed under the chin, and is carried upward on the same 
line until it reaches the point of starting. The same turns 
are repeated until three complete turns have been made ; 
the bandage is then continued until it reaches a point just 
above the ear, when it is reversed and is carried backward 



GIBSON'S BANDAGE. 45 

around the occiput, and is continued around the head and 
forehead until it reaches its point of origin ; these circular 
turns are continued until three have been made. When 
the bandage reaches the occiput, having completed the 
third turn, it is allowed to drop down to the base of the 
skull, and it is then carried forward below the ear and 
around the chin, being brought back upon the opposite side 
of the head and neck to the point of origin ; these turns 
are repeated until three complete turns have been made, 

Fig. 39. 




Gibson's bandage. 



and upon the completion of the third turn the bandage is 
reversed and carried forward over the occiput and vertex 
to the forehead, and its extremity is here secured with a 
pin. Pins should also be applied at the points where the 
turns of the bandage cross each other. (Fig. 39 ) 

Use. — This bandage may be used to fix the lower jaw 
in cases of fracture or dislocation of the jaw, but is very 
apt to change its position, and is, therefore, not so satis- 
factory as the Barton's bandage for this purpose. 



46 BANDAGING. 

Oblique Bandage of Angle of the Jaw. 

Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller is 
placed just in front of and above the left ear, and if the 
left angle of the lower jaw is to be covered in, the bandage 
is to be carried from left to right, making two complete 
turns around the cranium from the occiput to the fore- 
head. If however the right angle of the lower jaw is to 
be covered in, the turns should be made in the opposite 
direction. 

Fig. 40. 




Oblique bandage of angle of the jaw. 

Having made two turns from the occiput to the fore- 
head, the bandage is allowed to drop down upon the neck, 
and is carried forward under the ear and under the chin 
to the angle of the jaw ; it is now carried upward close to 
the edge of the orbit, and obliquely over the vertex of the 
skull, then down behind the right ear, continuing this 
oblique turn under the chin to the angle of the left jaw, 
where it ascends in the same direction as the previous turn. 
Three or four of these oblique turns are made, each turn 
overlapping the preceding one and passing from the edge 



RECURRENT BANDAGE OF THE HEAD. 47 

of the orbit toward the ear until the space is covered in ; 
the bandage is then carried to a point just above the ear 
on the opposite side, is reversed, and finished with one or 
two circular turns from the occiput to the forehead, the 
extremity being secured by a pin. (Fig. 40.) 

Use. — This will be found to be one of the most useful 
of the head-bandages ; it may be used with a compress in 
treating fractures of the angle of the lower jaw, for holding 
dressings to the lower part of the chin and to the vault of 
the cranium, and is especially useful in retaining dressings 
to the sides of the face and the parotid region. As before 
stated, it may be applied to cover either the right or left 
side of the face, and, by reason of the oblique turns, holds 
its position most securely, having little tendency to become 
displaced. 

Recurrent Bandage of the Head. 
Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the lower part of the forehead and the ban- 
dage is carried twice around the head from the forehead to 
the occiput to secure it. When the bandage is brought 
back to the median line of the forehead it is reversed and 
the reversed turn is held by the finger of the left hand 
while the roller is carried over the top of the head along 
the sagittal suture to a point just below the occipital pro- 
tuberance ; here it is reversed again and the reverse is 
held by an assistant while the roller is carried back to the 
forehead in an elliptical course, each turn covering in two- 
thirds of the preceding turn. These turns are repeated 
with successive reverses at the forehead and occiput until 
one side of the head is completely covered in, and when 
this is accomplished a circular turn is made from the fore- 
head to the occiput to hold the reverses in place. 

The opposite side of the head is next covered in by 
elliptical reversed turns made in the same manner, and 
when this has been accomplished two or three circular 



48 BANDAGING. 

turns are carried around the head from the forehead to the 
occiput to fix the previous turns. Pins should be applied 
at the forehead and occiput at the points where the re- 
versed turns concentrate. (Fig. 41.) 



Fig 




Recurrent bandage of the head. 

Use. — This bandage when well applied is one of the 
neatest of the head-bandages, and it will be found useful 
to retain dressings to the vault of the cranium in the treat- 
ment of wounds of the scalp in this region. It will also 
be found of service in holding dressings to fractures of the 
cranium and to wounds after the operation of trephining. 
In restless patients it will sometimes become displaced, 
and it may be rendered more secure by pinning a strip of 
bandage to the circular turn in front of the ear and carry- 
ing it down under the chin and up to a corresponding 
point on the opposite side, where it is pinned to the cir- 
cular turn ; or one or two oblique turns passing from the 
circular turn over the vertex of the skull downward behind 
the ear, under the chin and up to the circular turn in front 
of the ear, may be applied. The course of these turns is 
the same as those employed in the oblique bandage of the 
angle of the jaw, the extremity being secured by a pin. 



TRANSVERSE RECURRENT BANDAGE OF HEAD. 49 

Tpansvekse Recukrent Bandage of Head. 

Roller Two Inches in Width, Six Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the lower part of the forehead and the ban- 
dage is carried twice around the head from the forehead to 
the occiput to secure it. The head is then covered in by 
transverse turns of the bandage ; the first turn, starting 
from a point behind the ear on one side, is carried below 
the occiput to a corresponding point behind the opposite 

Fig. 42. 




Transverse recurrent bandage of the head. 

ear, and ascending transverse turns are then made and 
carried over the head, each turn covering in about two- 
thirds of the preceding turn, until the forehead is reached, 
and when this has been reached two or three circular turns 
are carried around the head from the forehead to the 
occiput to fix the recurrent turns. Pins should be applied 
at the point of starting of the reversed turns behind the 
ears, and at the occiput and forehead. (Fig. 42.) 

Use. — This bandage may be employed to secure dress- 
ings to the scalp in case of wounds, or in injuries to the 



50 BANDAGING. 

skull, and is used for the same purposes as the recurrent 
bandage of the head. 

Y-BANDAGE OF THE He AD. 

Boiler Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the roller is 
secured by two turns of the bandage around the cranium 
from the forehead to the occiput, and when the roller 
reaches the occipital protuberance it is allowed to drop 
slightly a little below this and is carried forward below 
the ear around the front of the chin and lower lip, then 

Fig. 43. 




V-bandage of the head. 

backward to the point of starting. These turns passing 
from the occiput to the forehead and from the occiput to 
the chin are alternately made nntil a sufficient number 
have been applied, and the extremity is secured by a pin 
over the occiput. (Fig. 43.) 

This bandage may be modified by carrying the turns 
from the occiput forward under the ear and around the 
upper lip and back to the occiput and alternating these 
turns with the occipito-frontal turns ; if employed in this 



HEAD-AND-NECK BANDAGE. 51 

way, a bandage of one and one-half inches in width should 
be used. 

Use. — This bandage may be employed to hold dressings 
to the front of the chin, to the upper and lower lips in 
cases of wounds, or to give support to these parts after 
plastic operations. 

Head-and-neck Bandage. 
Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the forehead and carried backward just above 
the ear to the occiput and is then brought forward around 
the opposite side of the head to the point of starting. Two 

Fig. 44. 



Head-and-neck bandage. 



of these circular turns are made to fix the bandage, and 
when it is carried back to the occiput it is allowed to drop 
down slightly upon the neck and is then carried around the 
neck, the turns around the head alternating with the neck- 
turns until a sufficient number of these have been applied, 



52 BANDAGING. 

when the extremity of the bandage is secured by a pin at 
the point of crossing of the turns at the back of the 
head. (Fig. 44.) 

Use. — This bandage may be found useful in securing 
dressings to the anterior or posterior portion of the neck 
or to the region of the occiput. 

Care should be taken to apply it in such a manner that 
too much pressure is not made by the turns around the 
neck, which would be uncomfortable to the patient, and 
might seriously interfere with respiration. 

Ckossed Bandage of One Eye. 

Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the bandage is 
placed upon the forehead and fixed by two circular turns 
passing around the head from the occiput to the forehead ; 

Fig. 45. 




Crossed bandage of one eye. 



the roller is then carried back to the occiput and passed 
around this and brought forward below the ear, and pass- 
ing over the outer portion of the cheek is carried upward 
to the junction of the nose with the forehead, and is then 
conducted over the parietal eminence downward to the 



CROSSED BANDAGE OF BOTH EYES. 53 

occiput ; a circular fronto-occipital turn is next made, and 
when the bandage is brought back to the occiput it is 
brought forward again to the cheek. It should then 
ascend to the forehead, covering in two-thirds of the 
previous turn, and be again conducted back to the occi- 
put ; these turns are repeated, the oblique turns covering 
the eye alternating with circular turns around the head 
until the eye is completely enclosed (Fig. 45), and the 
bandage is finished by making a circular turn about the 
head and introducing a pin to secure its extremity. It 
will be found more comfortable to the patient to include 
the ear on the same side on which the eye is covered in 
the turns of the bandage. 

Use. — This bandage will be found useful in retaining 
dressings to one eye. It will be more comfortable to the 
patient if a flannel roller be used to apply this bandage, 
as well as the bandage which includes both eyes. 

Crossed Bandage of Both Eyes. 

Boiler Two Inches in Width, Six Yards in Length. 

Application.— The initial extremity of the roller is 
placed upon the forehead and secured by two circular turns 
of the bandage, passing around the head from the forehead 
to the occiput ; the roller is then carried downward behind 
the occiput and brought forward below the ear to the upper 
portion of the cheek ; it is then carried upward to the 
junction of the nose with the forehead and conducted over 
the parietal eminence to the occiput; a circular turn is 
now made around the head from the occiput to the fore- 
head, and the roller is carried from the occiput over the 
parietal eminence of the opposite side forward to the 
junction of the nose with the forehead, then downward 
over the eye and outer portion of the cheek below the ear 
and back to the occiput ; a circular turn around the head 
is next made, and this is followed by a repetition of the 
previous turns, ascending over one eye, descending over 
the other eye, each turn alternating with a circular turn 



54 BANDAGING, 

around the head. These turns are repeated until both 
eyes are covered in, and the bandage is finished by making 
a circular turn around the head, the extremity being 
secured by a pin. (Fig. 46.) In this bandage both ears 
may be covered in, or left uncovered. 




Crossed bandage of both eyes. 

Use. — This bandage may be used to apply dressings to 
both eyes, and both of these bandages covering the eyes 
are used where it is desired to make pressure; but, for the 
simple application of a light dressing or of a bandage for 
the exclusion of light, the Liebrich's bandage (Fig. 76) 
Avill be found more comfortable to the patient. 

OCCIPITOFACIAL BANDAGE. 

Roller Two Inches in Width, Four Yards in Length. 

The initial extremity of the roller is placed upon the 
vertex of the head and the bandage is carried downward 
in front of the ear, under the jaw, and upward upon 
the opposite side in the same line to the vertex ; two or 
three of these turns are made, one turn accurately cover- 



OBLIQUE BANDAGE OF THE HEAD. 55 

ing in the other. A reverse should be made just above 
and in front of the ear, and two or three turns are then 
made around the head from the occiput to the forehead, 
which completes the bandage. (Fig. 47.) Pins should be 
inserted at the points where the turns of the bandage 
cross each other. 



Fig 




Occipito-facial bandage. 

Use. — This bandage is employed to secure dressings to 
the vertex, temporal, occipital, or frontal region. 

Oblique Bandage of the Head. 

Roller Two Inches in Width, Six Yards in Length. 

The initial extremity of the bandage is placed upon the 
forehead, and is secured by two circular turns passing 
around the head from the forehead to the occiput. From 
the occiput the bandage is carried obliquely over the 
highest part of the lateral aspect of the head, which is to 
be covered in, and is passed over the forehead and back to 
the occiput. It is then carried to the forehead by a circu- 
lar turn, which is conducted obliquely over the other side 01 



56 BANDAGING. 

the head and back to the occiput. A circular turn from 
the occiput to the forehead should be made between the 
oblique turns. These turns are repeated, so that each 
succeeding turn covers in three-fourths of the preceding 
turn until the sides of the head are covered in by de- 
scending turns, and the bandage is completed by a cir- 
cular turn passing around the head from the forehead to 
the occiput. (Fig. 48.) This bandage may be applied 
with descending or ascending turns. 

Fig. 48. 




Oblique bandage of the head. 

Use. — This bandage is employed to make pressure upon 
or to hold dressings to the lateral aspects of the head. 

Occipitofrontal Bandage. 

Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the forehead, and a circular turn is made 
around the forehead and occiput to fix it. A circular turn 
is then made passing around the head from a point below 
the occiput to a point just above the forehead ; the next 
circular turn is made around the head ascending pos- 
teriorly and descending anteriorly, and after a sufficient 



SPIRAL BANDAGE OF THE FINGER. 57 

number of these turns have been made to cover in the 
front and back of the head, the end of the bandage is 
secured with a pin. (Fig. 49.) 



Fig 




Occipitofrontal bandage. 

Use. — This bandage will be found useful in securing 
dressings to the forehead and anterior and posterior por- 
tions of the scalp. 

Bandages of the Upper Extremity. 

Spiral Bandage of the Fixgeb. 

Roller One Inch in Width, One and a Half Yards in 
Length. 

Application. — The initial extremity of the roller is 
secured by two or three turns around the wrist ; the ban- 
dage is then carried obliquely across the back of the hand 
to the base of the finger to be covered in, then to its tip 
by oblique turns ; a circular turn is then made and the 
finger is covered by ascending spiral or spiral reversed 



58 BANDAGING. 

turns until its base is reached; the bandage is then carried 
obliquely across the back of the hand and finished by one 
or two circular turns around the wrist ; the extremity may 
be pinned or may be split into two tails, which are tied 
around the wrist. (Fig. 50.) 

Fig, 50. 




Spiral*bandage of the finger. 

Use. — This bandage is employed to retain dressings 
upon the finger and to secure splints in the treatment of 
fractures or dislocations of the phalanges. 

Gauntlet-bandage. 

Roller One Inch in Width, Three Yards in Length. 

Application. — The initial extremity of the roller is 
fixed at the wrist by one or two circular turns of the ban- 
dage ; it is then carried down to the tip of the thumb by 
an oblique turn of the roller, and this is covered in by 



GA UNTLET-BANDA GE. 59 

spiral or spiral reversed turns to the metacarpophalangeal 
articulations ; the roller is then carried back to the wrist 
and a circular turn is made around it. The bandage is 
then carried down to the tip of the next finger by an 
oblique turn, which is covered-in in the same manner. 
When all the fingers have been covered in, the bandage 
is finished bv circular turns around the hand and wrist. 
(Fig. 51.) 

Fig. 51. 




Gauntlet-bandage. 

Use. — This bandage may be employed to apply dress- 
ings to the fingers and hand in case of wounds or frac- 
tures. It was formerly much employed in the treatment 
of burns of the fingers to prevent the opposed ulcerated 
surfaces from adhering, but its use for this purpose has 
been supplanted by wrapping each finger in a separate 
dressing and applying a dressing over the whole with a 
few recurrent and spiral turns of a wide roller, the applica- 
tion of this dressing being much less painful to the patient, 
and being at the same time equally satisfactory in its 
results. 



60 BANDAGING. 

Demi-gauntlet Bandage. 
Roller One Inch in Width, Four Yards in Length. 

Application. — The initial extremity of the bandage 
should be placed upon the wrist and fixed by two circular 
turns passing from the ulnar to the radial side; then carry 
the roller obliquely across the back of the hand to the base 
of the little finger, pass the bandage around this and carry 
the roller back to the wrist, making a circular turn ; it 

Fig. 52. 




Demi-gauntlet bandage. 

should then be carried obliquely across the hand to the base 
of the next finger, and so successively until the base of 
each of the fingers and of the thumb has been included ; 
the bandage is then completed by a circular turn around 
the wrist. (Fig. 52.) 

The demi-gauntlet bandage may also be applied in such 
a manner as to cover only the palm and leave the dorsum 
of the hand uncovered. 



SPICA-BANDAGE OF THE THUMB. 



61 



Use. — This bandage may be employed to retain light 
dressings to the dorsal or palmar surface of the hand. 

Spica-baxdage of the Thumb. 



Fig. 53. 



Roller One Inch in Width, Three Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the wrist and fixed by two circular turns; then 
carry the roller obliquely over 
the dorsal surface of the thumb 
to its distal extremity ; next 
make a circular or spiral turn 
around the thumb, and carry the 
bandage upward over the back of 
the thumb to the wrist, around 
which a circular turn should be 
made. The roller is next car- 
ried around the thumb and wrist, 
making figure-of-eight turns, 
each turn overlapping the pre- 
vious one two-thirds as it as- 
cends the thumb, and each figure- 
of-eight turn alternating with a 
circular turn about the wrist. 
These turns are repeated until 
the thumb is completely covered in with spica-turns, and 
the bandage is finished by a circular turn around the 
wrist. (Fig. 53.) 

Use. — This bandage is employed to apply dressings to 
the dorsal surface of the thumb, and for the retention of 
splints in the dressings of fractures or dislocations of the 
bones of the thumb. 




S pica-ban dage of the thumb. 



62 BANDAGING. 

Spiral Reversed Bandage of the Upper 
Extremity. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed upon the wrist, and secured by two turns around 
the wrist; the bandage is then carried obliquely across the 
back of the hand to the second joint of the fingers, where, 
a circular turn should be made; the hand is covered in by 
two or three ascending spiral or spiral reversed turns. 
When the thumb has been reached, its base and the wrist 
are covered in by two figure-of-eight turns ; the bandage 
is then carried up the forearm by spiral and spiral reversed 

Fig. 54. 




Spiral reversed bandage of the upper extremity. 

turns until the elbow is reached ; this may be covered in 
with spiral reversed turns, and the bandage is next carried 
up the arm with spiral reversed turns to the axilla. (Fig. 54.) 
If, on reaching the elbow, the arm is bent, or is to be flexed 
in the subsequent dressing, the elbow should be covered in 
with figure-of-eight turns, and when this has been done the 
arm may be covered in with spiral reversed turns. When 
properly applied, the reverses should be in a line, and 
should not be made over the prominent ridge of the ulna. 



FIGURE-OF-EIGHT BANDAGE OF THE ELBOW. 63 

Use. — This is one of the most generally employed of all 
the roller-bandages ; it constitutes the primary roller which 
is applied in the dressing of fractures of the humerus, and 
it is also the bandage employed in holding dressings to the 
arm and forearm, and in securing splints to these parts in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Elbow. 

Roller Two Inches in Width, Four Yards in Length. 

Application. — The initial extremity of the bandage is 
placed upon the forearm a short distance below the elbow- 

Fig. 55. 




Figure-of-eight bandage of the elbow. 

joint, and fixed by one or two circular turns, the arm being 
flexed. The bandage is then carried by an oblique turn 



64 BANDAGING. 

across the flexure of the elbow-joint, and passed around 
the arm a few inches above the elbow ; a circular turn is 
then made, and the roller is next carried across the flexure 
of the elbow and passed around the forearm. These turns 
are repeated, the turns from the forearm ascending and 
those from the arm descending, each set of turns crossing 
in the flexure of the elbow until it is covered in, and a 
final turn is passed circularly around the elbow-joint. 
(Fig. 55.) This bandage is sometimes applied by first 
making one or two circular turns around the elbow and 
then applying the figure-of-eight turns as previously 
described. 

Use. — This bandage is often employed as a part of the 
spiral reversed bandage of the upper extremity when the 
arm is to be flexed, and is also used to hold dressings to the 
region of the elbow-joint. It was formerly much used to 
hold the compress upon the wound resulting from venesec- 
tion at the elbow. 

Spica-bandage of the Shoulder (Ascending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed obliquely upon the outer surface of the arm opposite 
the axillary fold, and fixed by one or two circular turns. It 
the right shoulder is to be covered, the bandage is next 
carried across the front of the chest to the axilla of the 
opposite side, then around the back of the chest to the 
point of starting upon the arm ; then the roller should be 
conducted around the arm of this side up over the shoulder, 
across the front of the chest, through the opposite axilla 
and back over the posterior surface of the chest to the point 
of starting ; continue to make these ascending turns, each 
turn overlapping the preceding one about two-thirds until 
the shoulder is covered in (Fig. 56), when the extremity of 
the bandage may be secured by a pin at the point of end- 
ing, or the last turn may be carried from the shoulder 



SPICA-BANDAGE OF THE SHOULDER. 65 

around the back of the neck and brought forward over 
the opposite shoulder and piuned to the turns which pass 
around the axilla. It should be remembered that the 
turns of the roller overlap each other exactly in the oppo- 
site axilla, and it will be found more comfortable to the 
patient to apply a little cotton-wadding in the axilla to 
prevent the bandage from excoriating the skin of this part. 
Care should be taken to see that the turns are made in such 

Fig. 56. 




S pica-bandage of shoulder ^ascending). 

a manner that the spica-turns occupy, as nearly as possible, 
the median line of the shoulder. When this bandage is 
applied to the left shoulder, after fixing the initial ex- 
tremity by circular turns around the arm, the roller should 
be carried over the back of the chest to the axilla of the 
opposite side and then brought back to the point of start- 
ing ; the succeeding turns are then applied in the same 
manner. 



66 



BANDAGING. 



Spica-bandage of the Shoulder (Descending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller 
should be fixed upon the arm as near as possible to the 
axillary fold by one or two circular turns; and if it is 
applied to the right shoulder, the bandage should be passed 
under the axilla and carried obliquely over the shoulder 
to the base of the neck, then downward across the front of 
the chest to the axilla of the opposite side ; from the axilla 



FIG. 57. 




Spica-bandage of shoulder (descending). 

the roller is carried over the back of the chest to the base 
of the neck so as to cross the first turn at this point ; it is 
then carried through the axillary space, then back to 
the neck, the turns descending toward the shoulder. 
These turns, taking the same course, are repeated, each 
turn overlapping two-thirds of the previous one until the 
shoulder is covered in and the circular turn around the 



FIGURE-OF-EIGHT BANDAGE. 



67 



arm is reached, at which point the extremity is secured 
by a pin. (Fig. 57.) 

Use. — The spica-bandages of the shoulder are employed 
to hold dressings to the shoulder, to hold compresses over 
the acromial end of the clavicle in case of dislocation of 
that portion of the bone, to retain the shoulder-cap used 
in the treatment of fractures of the upper portion of the 
humerus, and to retain dressings to the axilla. 



Figure-of-eight Bandage of the Neck and 
Axilla. 



Fig. 58. 



Roller Two Inches in Width, Five Yards in Length. 

Application. — The initial extremity of the roller is 
fixed upon the side of the neck and secured by one or two 
loosely applied circular turns ; if applied to the right 
axilla, carry the bandage from left to right over the right 
shoulder to the posterior part 
of the axilla under which it 
passes, to ascend in front 
over the same shoulder to 
the back of the neck ; these 
figure-of-eight turns around 
the neck and axilla, each 
turn overlapping two-thirds 
of the previous turn, are 
repeated until the desired 
space is covered and the ban- 
dage is completed by a cir- 
cular turn around the neck. 

(Fi K . 58.) 

Use. — This will be found 
a useful bandage to secure dressings to the base of the 
neck, the upper part of the shoulder, and to the axilla, 
as it does not restrict the motions of the arm unless 
drawn too tight. 




Figure-of-eight bandage of the 
neck and axilla. 



68 BANDAGING. 



Velpeau's Bandage. 

Two Rollers Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The patient should place the fingers of 
the hand of the affected side on the opposite shoulder ; the 
initial end of the roller should be placed on the body of 
the scapula of the sound side and secured by a turn made 
by carrying the bandage over the shoulder of the affected 
side, near its outer portion, then conducting it downward 
over the outer and posterior surface of the arm of the same 

Fig. 59. 




Velpeau's bandage. 

side, behind the point of the elbow, and obliquely across 
the front of the chest to the axilla of the opposite side, 
thence to the point of starting. This turn should be 
repeated, to fix the initial extremity of the bandage. 
Having completed the second turn, carry the roller trans- 
versely around the thorax, passing over the flexed elbow 
of the affected side, from this point to the axilla, and 
through this to the back. From this point the roller is 



DESATJLTS BANDAGE. 69 

carried over the shoulder and down the outer and posterior 
surface of the arm behind the elbow and obliquely across 
the front of the chest through the axilla to the back, and 
continuing, passes transversely across the back of the chest 
to the elbow, which it encircles, then passes to the axilla. 
These alternating turns are repeated until the arm and 
forearm are bound firmly to the side and chest. The 
vertical turns over the shoulder, each turn covering in 
two-thirds of the previous turn and ascending from the 
point of the shoulder toward the neck and from the 
posterior surface of the arm toward the elbow, are applied 
until the point of the elbow is reached. The transverse 
turns passing around the chest and arm are so applied that 
they ascend from the point of the elbow toward the 
shoulder, each turn covering in one-third of the previous 
one, and the last turn should pass transversely around the 
shoulder and chest, covering the wrist. (Fig. 59.) 

The extremity of the bandage should be secured by a 
pin where it ends, and additional fixation will be secured 
by introducing a number of pins at the points where the 
turns of the bandage cross each other. 

Use. — This bandage is employed to fix the arm in the 
treatment of certain fractures of the clavicle and scapula, 
also to secure fixation of the humerus after the reduction 
of dislocations of the shoulder-joint. 



Desault's Bandage. 

Three Rollers Two and a Half Inches in Width, Seven 
Yards in Length. 

A wedge-shaped pad to fit in the axilla is also required. 
These rollers are known as the first, second, and third 
rollers. 

First Roller of Desault's Bandage. 

Application. — Before applying the first roller the arm 
of the patient on the injured side should be elevated and 

4* 



70 BANDAGING. 

carried off at right angles to the body ; the wedge-shaped 
pad with its base in the axilla should next be applied to 
the side of the chest, and the initial extremity of the roller 
should be placed upon the middle of the pad, which may 
be fixed by two or three circular turns around the chest; 
the bandage is then carried down the chest by oblique 
circular turns until the lower extremity of the pad is 

Fig. 60. 




First roller of Desault's bandage. 

reached, and it is then carried up the chest until the upper 
extremity of the pad is reached, when it is conducted 
obliquely across the front of the chest to the sound 
shoulder and passed under the axilla, brought over the 
shoulder and conducted around the chest, where it is 
secured. (Fig. 60.) 

Second Roller of DesauWs Bandage. 

Application. — The arm should be brought down 
against the side so as to press upon the pad previously 
applied, and the forearm should be flexed upon the arm 
and brought across the lower portion of the chest. The 
initial extremity of the roller is placed in the axilla of 
the sound side, and the bandage is carried around the chest 



DESAULTS BANDAGE. 



71 



and over the arm of the injured side, making a circular 
turn around the chest to fix it; then spiral turns are made 
around the chest from above downward until the elbow is 
reached, the turns being more firmly applied as they de- 
scend, and when this point is reached the end of the ban- 
dage is secured. Or the initial extremity of the bandage 

Fig. 61. 




Second roller of Desault's bandage. 



may be placed upon the chest of the sound side and a 
circular turn may be made to fix it, and then spiral turns, 
including the chest and arm, may be made from below 
upward until the axilla is reached. (Fig. 61.) 



Third Roller of DesauWs Ba?idage. 

Application. — The initial extremity of the roller is 
placed in the axilla of the sound side, and the bandage is 
carried obliquely over the front of the chest to the shoulder 
of the injured side, passed over this, and conducted down 
the back of the arm to the elbow, thence obliquely upward 
over the upper fifth of the forearm to the axilla of the 
sound side. From this point it is carried backward ob- 
liquely over the back of the chest to the shoulder ; crossing 



72 



BANDAGING. 



the previous shoulder-turn , it is conducted down the front 
of the arm to the elbow, then around this and backward 
obliquely over the back of the chest to the axilla of the 
sound side. These turns are repeated until three sets 
of turns have been applied, which should overlie each 
other exactly. (Fig. 62.) The course of the turns of the 
third roller is considered the most difficult to remember, 
and the student may be assisted in its correct application 
by remembering that all the turns start at the axilla, 
pass to the shoulder, and then to the elbow, and from the 
elbow always return to the starting-point — the axilla. 



Fig. 62. 




Third roller of Desault's bandage. 



The turns of the third roller make two triangles, one on 
the anterior surface of the chest, the other upon the back. 
(Fig. 63.) 

After the application of the three rollers the hand and 
uncovered portion of the forearm should be supported in 
a sling suspended from the neck. 

Use. — This bandage, applied completely, or some one 
of its various rollers, is employed in the treatment of 
fractures of the clavicle. 



ARM-AND-CHEST BANDAGE. 
Fig. 63. 



73 




Posterior view of turns of third roller of Desault's bandage. 

Arm-axd-chest Bandage. 

Roller Two and a Halj Inches in Width, Seven Yards in 

Length. 

Before applying this bandage the arm should be placed 
against the side of the chest and a folded towel or a pad 
of cotton should be placed in the axilla and allowed to 



74 BANDAGING. 

extend from the axilla to the elbow ; the latter is used to 
prevent the opposing surfaces of skin from becoming ex- 
coriated by contact. 

Application. — The initial extremity of the bandage 
is placed upon the spine at a point opposite the elbow- 
joint, and it is fixed by a turn or two passing around the 

Fig. 64. 




Arin-and-chest bandage. 

arm and chest ; the bandage is then continued by making 
ascending spiral turns, covering in the arm and chest until 
the axilla is reached ; at this point the baudage is carried 
through the axilla and over the back of the chest to the 
top of the opposite shoulder, and it is then conducted 
down the front of the arm to the elbow, is passed between 



SPIRAL BANDAGE OF THE CHES1. 



75 



the arm and chest and carried up the back ot the arm to 
the shoulder. It is then passed obliquely across the front 
of the chest and is secured upon the back of the chest. 
Pins should be introduced at the points of crossing of the 
bandage. (Fig. 64.) 

Use. — This bandage will be found useful in fixing the 
arm to the body and in fixing the shoulder-joint where it 
is desirable to allow the forearm to be free. It is em- 
ployed in the treatment of fractures of the shaft and neck 
of the humerus to fix the arm and hold splints in position. 

Bandages of the Trunk. 
Spiral Bandage of the Chest. 

Roller Three Inches in Width, Nine Yards in Length, 

Application. — The initial extremity of the roller is 
applied to the anterior portion of the waist, and fixed by 
one or two circular turns ; the bandage is then carried 

Fig. 65. 




Spiral "bandage of the chest. 



upward, encircling the chest by ascending spiral turns, 
each turn covering in one-half of the previous turn until 



76 



BANDAGING. 



the axillary fold is reached; the roller is next carried 
around the axilla to the back, and obliquely over this to 
the base of the neck of the opposite side, and then it may 
be passed down over the chest and pinned to the spiral 
turns at several points ; a pin should also be inserted at 
the point where the last turn of the roller leaves the spiral 
turn upon the back of the chest. (Fig. 65.) 

Use. — This bandage is employed to hold dressings to 
the chest, and may be used as a temporary dressing in 
fractures of the ribs or sternum. Care should be taken 
that the bandage be not so tightly applied as to interfere 
with respiration. 

Anterior Figure-of-eight Bandage of the 
Chest. 



Roller Two and a Half Inches in Width, Seven Yards in 

Length. 

Application. — The initial extremity of the roller 
should be placed in the axilla of one side, and the ban- 

FlG. 66. 




Anterior figure-of-eight bandage of the chest. 

dage is then carried obliquely across the anterior portion 
of the chest to the shoulder of the opposite side ; it is then 
carried backward around the shoulder and through the 



FIGURE-OF-EIGHT BANDAGE OF CHEST. 77 

axilla, and is next conducted obliquely over the anterior 
portion of the chest to the opposite shoulder, through the 
axilla and again back to the anterior portion of the chest, 
the turns crossing in the median line over the sternum. 
These turns should be repeated, ascending from the 
shoulder toward the neck, each turn overlapping three- 
fourths of the preceding one, until five or six turns have 
been applied, the end of the bandage being secured by a 
pin (Fig. 66), or it may be completed by a circular turn 
around the chest. 

Use. — This bandage may be employed to bring the 
shoulders forward, and to hold dressings to the anterior 
portion of the chest. 

Posterior Figure-of-eight Bandage of the 
Chest. 

Roller Tico and a Half Inches in Width, Seven Yards 
in Length. 

Fig. 67. 




Posterior figure-of-eight bandage of the chest. 

Application. — The initial extremity of the roller 
should be placed in the axilla of the left side, and the 



78 BANDAGING. 

bandage should then be carried obliquely across the back 
of the chest to the tip of the opposite shoulder; it is next 
carried through the axilla and conducted across the poste- 
rior portion of the chest to the tip of the opposite shoulder, 
and passed through the axilla to the point of starting. 
These turns are repeated, ascending from the shoulder to- 
ward the neck, until five or six have been applied, the end 
of the bandage being secured by a pin. (Fig. 67.) In 
applying both of these bandages the crosses of the ban- 
dage, either anterior or posterior, should be made in the 
median line of the chest. 

Use. — This bandage may be employed to hold dressings 
to the posterior portion of the chest and to draw the 
shoulders backward. 



Suspensory and Compressor Bandage of the 
Breast. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller 
should be placed upon the scapula of the affected side, and 
secured by two oblique turns carried over the opposite 
shoulder and conducted downward under the breast to 
be covered in, and then carried to the axilla of the same 
side. Next carry the roller transversely around the chest, 
covering in the lowest portion of the affected breast. 
These turns should be repeated, the oblique turns from the 
axilla over the shoulder alternating with the transverse 
turns around the chest, until the breast is covered in, each 
series of turns ascending, and covering two-thirds of the 
preceding turn. (Fig. 68.) 

Use. — This bandage is employed to support the breast 
and to make compression at the same time ; it may also 
be employed to hold dressings to the breast. 



SUSPENSORY AND COMPRESSOR BANDAGES. 79 

Fig. 68. 




Suspensory and compressor bandage of the breast. 



Suspensory and Compressor Bandages of Both 
Breasts. 

Ttvo Boilers Two and a Half Inches in Widths Seven 
Yards in Length. 

Application. — The initial extremity of the bandage 
should be secured by oblique turns of the axilla and 
shoulder as in the preceding bandage ; the roller should 
next be carried transversely around the back to the breast, 
then under the breast and upward over the opposite 
shoulder, then obliquely downward around the chest to 
the other side, being carried transversely over the lower 
portion of both breasts to the point of starting upon the 
back. Repeat these oblique turns from the shoulder to 
the breast and from the breast to the shoulder, and alter- 
nate them with a transverse turn around the chest and 
over both breasts. Both series of turns should ascend, 
and each turn should overlap two-thirds of the preceding 
one. (Fig. 69.) 

Use. — This bandage is employed to support and com- 
press both breasts and to retain dressings to them. 



80 



BANDAGING. 

Fig. 69. 





Suspensory and compressor bandage of both breasts. 



Bandages of the Lower Extremity. 

Single Spica-bandage of the Groin (Ascending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Place the initial extremity of the ban- 
dage upon the anterior portion of the right thigh just 
below the groin and secure it by one or two circular turns 



SINGLE SPICA-BANDAGE OF THE GROIN 81 

around the thigh, or place the initial extremity of the roller 
obliquely upon the upper part of the thigh and carry it 
behind the limb and upward around the outer side of the 
thigh to the abdomen, omitting the circular turns ; then 
carry the bandage obliquely across the lower part of the 
abdomen to a point just below the crest of the left ilium 
and conduct it transversely around the back of the pelvis 

Fig. 70. 




Ascending spica-bandage of the groin . 

to a corresponding point on the opposite side ; then bring 
it obliquely downward to the groin over to the inner por- 
tion of the thigh, carrying it around the limb, crossing 
the starting-turn in the middle line of the thigh. These 
turns are repeated, each turn ascending and covering in 
two-thirds of the previous turn, until six or eight com- 
plete turns have been made, and the bandage is secured at 
any point where it ends. (Fig. 70.) 

Single Spica-bandage of the Groin (Descending). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Place the initial extremity of the roller 
obliquely upon the anterior surface of the right thigh and 



82 



BANDAGING. 



secure it by one or two circular turns around the limb, or 
start the bandage with an oblique turn, as previously 
described; then carry the bandage obliquely across the 
abdomen to a point just below the crest of the ilium, and 
conduct it transversely around the back of the pelvis to a 
corresponding point on the opposite side ; then bring it 
obliquely down over the lower portion of the abdomen, 
crossing the first turn, to the junction of the thigh with 
the scrotum, pass it under the thigh and bring it up over 
the lower part of the abdomen, and let it follow the course 



Fig. 71. 




Descending spica-bandage of the groin. 



of the first turn. These turns are repeated, each turn 
descending and overlapping two-thirds of the previous 
turn until the groin is covered. (Fig. 71.) When either of 
these bandages is applied to the left groin, after the initial 
extremity of the roller is fixed, it is carried first to the crest 
of the ilium of the same side, then around the back of the 
pelvis to a corresponding point on the opposite side, then 
obliquely across the lower part of the abdomen to the 
outer aspect of the thigh, being conveyed under this aud 
brought up between the thigh and the scrotum, passing 
obliquely over the groin to follow the course of the 
original turn. 



DOUBLE SPICA-BANDAGE OF THE GROINS. 83 

Double Spica-baxdage of the Groins. 
Holler Three Inches in Width, Nine Yards in Length. 

Application. — The initial extremity of the roller is 
placed upon the abdomen just above the iliac crests and 
secured by one or two circular turns ; the bandage is then 
carried from a point just below the crest of the right ilium 
obliquely across the lower portion of the abdomen to the 
outer portion of the left thigh, and is carried around this 
and brought up between the scrotum and the thigh, and is 

Fig. 72. 




I 



Double spica-bandage of the groins. 

passed obliquely over the groin, crossing the previous turn 
in the median line, and is conducted to a point just below 
the crest of the ilium on the same side. The bandage is 
then continued around the pelvis to the same point on the 
opposite side, and from this point is made to pass obliquely 
over the groin to the inner side of the thigh, passing 
around this and coming up on its outer side, crossing the 
previous turn at the middle line of the groin, to be carried 
obliquely across the groin and lower part of the abdomen 



84 BANDAGING. 

to the crest of the ilium on the opposite side. These turns 
are repeated, each turn covering in two-thirds of the pre- 
vious turn, until both groins have been covered. (Fig. 72.) 
The turns may be so applied as to ascend or descend, 
forming the ascending or descending double spica-bandage 
of the groin. When properly applied, this bandage pre- 
sents three sets of crossing-turns, one in each groin and 
one in the median line of the abdomen. 

Use. — The spica-bandages of the groin, either single or 
double, are employed to hold dressings to wounds in the 
inguinal region —for instance, those resulting from herni- 
otomy, or from operation upon the glands of the groin. 
They are also employed to make pressure upon this region, 
and will often prove of use in the securing of compresses 
applied for the temporary retention of hernise. 

Spica-bandage of Buttock. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Fig. 73. 




Spica-bandage of buttock. 



FIGURE-OF-EIGHT BANDAGE OF KNEE. 85 

Application. — The initial extremity of the bandage 
is placed upon the back of the thigh just below the gluteal 
fold, and is carried around the thigh and brought back to 
the posterior aspect of the limb so as to fix and cross the 
starting turn near the middle of the thigh. It is next 
conducted obliquely across the thigh and buttocks and 
carried to the brim of the pelvis of the opposite side, when 
it is brought obliquely over the abdomen and back to the 
posterior surface of the thigh. There ascending turns are 
applied, each turn covering in about three-fourths of the 
preceding one, until the buttock is covered, and the ban- 
dage is then finished by one or two circular turns around 
the pelvis and abdomen. (Fig. 73.) 

Use. — This bandage is employed to hold dressings to 
the upper posterior portion of the thigh, or the buttock. 

FiGUBE-OF-EIGHT BANDAGE OF THE KNEE. 

Roller Two and a Half Inches in Width, Five Yards 
in Length. 

Fig. 74. 




Figure-of-eight bandage of the knee. 

Application. — The initial extremity of the roller is 
placed upon the thigh three inches above the patella and 

5 



86 BANDAGING. 

secured by two or three circular tarns ; then conduct the 
bandage over the outer condyle of the femur across the 
popliteal space to the inner border of the tibia and around 
the anterior surface below the tubercle and head of the 
fibula, and make one circular turn ; the roller should then 
be carried obliquely across the popliteal space to the inner 
condyle of the femur, crossing the previous turn ; then 
carry it around the front of the thigh to the outer condyle ; 
repeat these turns, ascending toward the knee from the 
leg and descending from the thigh toward the knee, and 
finish the bandage by a circular turn over the patella. 
(Fig. 74.) 

Use. — This bandage is employed to hold dressings to 
the knee-joint either anteriorly or posteriorly. These 
figure-of-eight turns are often employed in covering the 
knee in applying the spiral reversed bandage of the lower 
extremity when it is desired that the patient be allowed to 
bend the knee. 



Figure-of-eight Bandage of Both Knees. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Place the knees of the patient together 
with a compress between them ; then place the initial ex- 
tremity of the roller upon one thigh, about three inches 
above the patella, and secure it by one or two circular 
turns around both thighs ; then conduct the roller from 
the outer condyle of the femur obliquely across the pop- 
liteal spaces of both legs to the head of the fibula on the 
opposite side, making a circular turn around both legs ; 
pass the roller from the head of the fibula on the opposite 
side across the popliteal space to the external condyle 
opposite the point of starting. 

Repeat these turns, descending from the thighs and 
ascending from the legs, until the knees are covered, and 
finish the bandage by carrying a turn of the bandage at 



SPICA-BANDAGE OF THE ¥001. 87 

right angles to the previous turns between the thighs and 
the legs. (Fig. 75.) 

Use. — This bandage is employed to secure fixation of 
the limbs after operations upon the perineum, and may also 

Fig. 75. 




Figure-of-eight bandage of both knees. 



be employed to obtain temporary fixation of the limbs in 
transporting cases of fracture of the neck of the femur, 
and after the reduction of dislocations of the head of that 
bone. 

Spica-bandage of the Foot. 

Roller Two and a Half Inches in Width, Five Yards 
in Length. 

Application. — Fix the initial extremity of the roller 
upon the ankle and secure it by two circular turns ; then 
carry the bandage obliquely over the dorsum of the foot to 
the metatarso-phalangeal articulation and make a circular 
turn around the foot at this point ; then continue it upward 
over the metatarsus by making two or three spiral reversed 
turns ; next carry the bandage parallel with the inner or 
outer margin of the sole of the foot, according to whether 



88 BANDAGING. 

it is applied to the right or left foot, directly across the 
posterior surface of the heel ; thence along the opposite 
border of the foot and over the dorsum, crossing the 
original turn in the median line of the foot. This com- 
pletes the first spica turn. These spica turns are repeated, 
gradually ascending by allowing each turn to cover in 
three-fourths of the preceding turn, until the foot is 
covered in with the exception of the posterior portion of the 
sole of the heel. (Fig. 76.) Care should be taken to see 

Fig. 76. 




Spica-bandage of the foot. 

that the turns cross each other in the median line and that 
they are kept parallel to each other throughout their course. 
Use. — This bandage will be found very useful when it is 
desired to make firm compression upon the foot or to retain 
dressings to it ; it is especially useful in the treatment of 
sprains of the ankle or the anterior tarsus. 



Bandage of Foot Covering the Heel (American). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed upon the leg just above the malleoli and fixed by 



BANDAGE OF FOOT N01 COVERING THE HEEL. 89 

two circular turns around the leg ; the bandage is then 
carried obliquely across the dorsum of the foot to the 
metatarsophalangeal articulation, at which point a circular 
turn is made ; two or three spiral or spiral reversed turns 
are then made, ascending the foot ; the roller is next car- 
ried directly over the point of the heel and continued back 
to the dorsum of the foot; thence beneath the instep around 
one side of the heel and up over the instep ; from this 

Fig. 77. 




Bandage of foot covering the heel. 

point it is carried beneath the instep around the other side 
of the heel and up in front of the ankle, from which point 
it may be continued up the leg. (Fig. 77.) 

Use. — This bandage is employed to cover in the foot 
and retain dressings to the foot and heel. 

Bandage of Foot not Covering the Heel (French). 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — Fix the initial extremity of the roller 
upon the leg just above the malleoli and secure it by two 
circular turns around the leg ; the bandage is then carried 



90 



BANDAGING. 



obliquely across the dorsum of the foot to the meta- 
tarsophalangeal articulation, and at this point a circular 
turn should be made The roller is now carried up the 
foot, covering it in with two or three spiral reversed turns, 
and at this point a figure-of-eight turn is made around the 
ankle and instep ; this should be repeated once, which will 
cover in the foot with the exception of the heel ; the ban- 
dage may then be continued up the leg with spiral reversed 
turns. (Fig. 78.) 

Fig. 78. 




Bandage of foot not covering the heel. 

Use. — This bandage may be employed to secure dress- 
ings to the foot, and is the one generally used to cover this 
part in applying the spiral reversed bandage of the lower 
extremity. 

Spiral Reversed Bandage of the Lower 
Extremity. 



Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — The initial extremity of the roller is 
placed upon the leg just above the malleoli and secured by 



FIGURE-OF-EIGHT BANDAGE OF LEG. 91 

two circular turns. It is then carried obliquely over the 
foot to the inetatarso-phalangeal articulation, where a cir- 
cular turn is made around the foot. Two or three spiral 
reversed turns and two figure-of-eight turns of the ankle 
and instep should be made, while just above the ankle 
one or two circular or spiral turns are made around 
the leg, and as the bandage is carried up the leg, as it 
increases in diameter, spiral reversed turns are made until 
it approaches the knee ; at this point, if the limb is to be 
kept straight, the spiral reversed turns may be continued 



Fig. 79 




Spiral reversed bandage of the lower extremity. 

over this region and up upon the thigh. If the knee is 
to be bent, figure-of-eight turns may be applied until the 
knee is covered, and then the thigh may be covered with 
spiral reversed turns. (Fig. 79.) To cover in the thigh 
as well as the leg, two bandages of the dimensions before 
given will be required. Care should be taken to keep the 
reverses in a line and not to make them over the spine of 
the tibia, as they may thus become painful to the patient. 
Use. — This is one of the most frequently employed of 
the roller bandages ; it is used to apply pressure to the 
lower extremity, to retain dressings, and to secure splints 
in the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Leg. 

Roller Two and a Half Inches in Width, Seven Yards 
in Length. 

Application. — This bandage differs from the spiral 
reversed bandage of the lower extremity only in the fact 



92 



BANDAGING. 



that when the swell of the calf is reached figure-of-eight 
turns are made around the leg instead of spiral reversed 
turns. In applying the roller, when the calf of the leg is 
reached, the bandage is carried obliquely around the leg 
to the crest of the tibia and made to cross the starting- 
turn in the median line ; these turns are repeated until 
the calf of the leg has been covered in, and the bandage 
is finished with one or two circular turns just below the 
knee. (Fig. 80.) 

Fig. 80. 




Figure-of-eight bandage of the leg. 



Use. — This bandage holds its place more firmly than 
the ordinary spiral reversed bandage of the leg, and may 
be employed in the treatment of ulcers of the leg in con- 
junction with strapping, where it is desirable to change 
the dressings at infrequent intervals and to allow the 
patient to walk about during the course of treatment. 



SPIRAL REVERSED BANDAGE OF THE PENIS. 93 



SPECIAL BANDAGES. 

Spiral Reversed Bandage of the Penis. 

Roller Three-quarters of an Inch in Width, Thirty Inches 
in Length. 

Application. — Fix the initial extremity of the roller 
by two circular turns around the penis close to the pubis ; 
then carry the bandage obliquely down to the corona 
glandis ; from this point ascend the body of the penis by 

Fig. 81. 




Spiral reversed bandage of the penis. 



spiral reversed turns to the pubis and finish the bandage 
by two figure-of-eight tarns around the neck of the scrotum 
and root of the penis ; split the end of the bandage so as 
to form two tails and secure it by tying these around the 
root of the penis. (Fig. 81.) 

5* 



94 SPECIAL BANDAGES. 

Kecukrent Bandage of Stump. 

Roller Two and a Half Inches in Width, Five to Seven 
Yards in Length. 

Application. — Place the initial extremity of the roller 
upon the anterior or posterior surface of the limb a few 
inches above the extremity of the stump, and carry the 
bandage to the end of the stump, and then conduct it 
upward or downward on the limb, as the case may be, to 
a point directly opposite the point of starting ; then bring 
the bandage back over the face of the stump to the point 
of starting and continue these recurrent turns, each turn 

Fig. 82. 




Recurrent bandage of stump. 

overlapping two-thirds of the previous one, until the face 
of the stump is covered ; then reverse the bandage and 
secure the recurrent turns at their points of origin by two 
or three circular turns. The roller should next be car- 
ried obliquely down to the end of the stump, and a cir- 
cular turn should be made around this. The bandage 
should next be carried up the limb by spiral or spiral 
reversed turns beyond the point at which the recurrent 



BANDAGE FOE LITHOTOMY POSITION. 95 

turns terminated, and secured by one or two circular turns. 
(Fig. 82.) ... 

In applying this bandage in very short stumps resulting 
from amputations at or near the shoulder or hip-joints, 
after making the recurrent and spiral turns, it will be 
found necessary to carry the bandage, in the case of the 
shoulder, across the chest to the opposite axilla and back, 
and apply several of these turns ; so in case of the hip 
amputations it will be found best to finish the bandage 
with a few turns about the pelvis. 

Bandage for Securing the Hands and Feet in 
the Lithotomy Position. 

Roller Two and a Half Inches in Width, Three Yards in 

Length. 




Bandage for securing the hands and feet for lithotomy. 

Application. — The hand of the patient should be 
brought down and made to grasp the outer side of the 
foot ; the initial extremity of the roller is fixed by two 



96 SPECIAL BANDAGES. 

circular turns around the wrist and ankle, and the bandage 
is then passed around the foot and hand, and these turns 
are alternated with turns around the wrist and ankle, until 
the hand and foot are firmly secured. The same procedure 
is adopted with the hand and foot of the opposite side. 
(Fig. 75.) 

Use. — This bandage is useful in securing the hands and 
feet while the patient is put in the lithotomy position for 
that operation, or for perineal section. 

Liebreich's Eye-bandage. 

This bandage consists of a strip of flannel two and a 
half inches in width and from six to ten inches in length, 

Fig. 84. 




Liebreich's eye-bandage. 

to the extremities of which tapes are sewed. It may be 
applied transversely so as to cover both eyes, or obliquely 
so as to cover one eye only, and it is secured by the tapes 
carried around the head and tied over the forehead. 
(Fig. 84.) 

Use. — This bandage is used to hold compresses or dress- 



BANDAGE OF SCULTETUS. 



97 



ings to the eye or eyes, and the elasticity of the flannel 
permits of its being applied so as to make a variable 
amount of pressure. 

Bandage of Scultetus. 

This is a compound bandage, consisting of a number of 
pieces of muslin, and may be prepared from a two and a 
half or three-inch roller by cutting off strips long enough 

Fig. 85. 




Bandage of Scultetus. 



to encircle the part about one and one-third times. These 
strips are placed under the part in such a manner that the 
first piece shall be overlapped by the second, the second 
by the third, and so on from below upward ; the pieces are 



98 SPECIAL BANDAGES. 

then brought around the limb, and the extremities of the 
last piece are secured by pins. (Fig. 85.) This bandage 
was formerly much employed in the treatment of com- 
pound fractures to secure dressings to the wound, and 
possessed the advantage that when a single strip became 
soiled it could be removed without disturbing the whole 
dressing, the new strip to be introduced being pinned to 
the extremity of the soiled piece to be removed, and then 
being drawn through by its removal. This bandage will 
often be found convenient in applying dressings to cases 
of excision of the joints, where as little disturbance of 
the parts as possible is important in dressing the wounds. 
When the strips are attached to each other by a thread 
passed through each strip in the centre, the bandage is 
known as Potfs bandage. This bandage is applied and 
secured in the same manner, but it possesses no advantages 
over the bandage of Scultetus. 

Flannel Bandage. 

These bandages are prepared from flannel which is cut 
into strips from two to four inches in width and from five 
to seven yards in length. These strips are formed into 
rollers either by hand or by means of the bandage-winder. 
Flannel bandages, by reason of the elasticity which they 
possess, can be applied without reverses and are used to 
make a moderate amount of elastic pressure. They are 
often employed in applying dressings to the head, espe- 
cially after operations upon the eyes, and are generally 
applied as a primary roller before the application of the 
plaster-of-Paris dressings, and may also be used in sub- 
acute joint-affections, both to protect the parts and make 
a moderate amount of elastic pressure. 

The Rubber Bandage. 

This bandage is made from a strip of rubber-sheeting, 
from one inch to four inches in width and from three to 



THE RUBBER BANDAGE. 



99 



five yards in length, which, for convenience of application, 
is rolled into a cylinder. 

Its use was introduced to the profession by Dr. Martin, 
of Boston, and it will be found a useful form of dressing 
where it is considered desirable to apply elastic pressure 
to a part, (Fig. 86.) 

It may be employed in the treatment of varicose veins 
of the legs, in chronic ulcers of those parts where pressure 




Martin's rubber bandage. 

is an important element in the treatment, and may be used 
as a substitute for strapping to secure this object. Its 
application has also been recommended in the treatment 
of swelled testicle in that stage of the affection in which 
pressure is indicated. 

Application. — For application to the leg a rubber 
bandage two and a half inches in width and three yards 
in length is required. 

The initial extremity of the roller is fixed upon the foot 
near the toes and secured by a circular turn ; the foot is 
then covered in by spiral turns overlapping each other 
about two-thirds, and a figure-of-eight turn is made from 
the ankle to the instep. The bandage is then carried up 
the limb to the knee with spiral turns, where it is secured 
by two tapes sewed to the terminal extremity of the ban- 
dage, which are passed around the leg and tied. The 
bandage need not be reversed, as its elasticity allows it to 
conform to the shape of the limb. Care should be taken 
not to apply the turns with too much firmness ; the 



100 SPECIAL BANDAGES. 

bandage should be stretched very slightly ; if this pre- 
caution is not taken, it soon becomes uncomfortable to the 
patient. A patient using one of these bandages will soon 
learn to apply it himself, making just the requisite amount 
of tension to secure its holding its place and to insure a 
comfortable amount of pressure upon the part. A well- 
fitting stocking may be placed upon the limb before the 
bandage is applied, or it may be applied directly to the 
skin. 

The bandage should be removed at night when the 
patient goes to bed and hung up to dry, as its inner sur- 
face becomes moist from the secretions from the skin ; it 
should be reapplied as soon as the patient rises in the 
morning. 

In, using it in the treatment of ulcers of the leg no oint- 
ments should be applied to the ulcer, as oily dressings soon 
destroy the rubber; dressings may be made to the ulcer by 
means of dry powders, such as oxide of zinc, iodoform, or 
aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is ap- 
plied to the testicle by means of recurrent turns not too 
firmly made, and secured in place by spiral turns, until 
the whole surface of the organ is covered in ; the end of 
the bandage is secured with tapes tied around the root of 
the scrotum. The same precaution to apply the bandage 
so as to make only moderate pressure should also be 
observed here. 

Fixed Dressings or Hardening Bandages. 

For the application of these dressings a variety of sub- 
stances are used which are incorporated in the meshes of 
some fabric, such as crinoline or cheese-cloth, or painted 
over its surface to give fixity or solidity to the bandage. 

The materials most commonly used in the preparation 
of fixed dressings are plaster-of-Paris, starch, silicate of 
sodium or potassium, paraffin, or a mixture of chalk and 
gum or of oxide of zinc and glue. 



THE PLASTEB-OF-PABIS BANDAGE. 101 

The Plaster-of-Paris Bandage. 

The plaster-of-Paris used for the application of surgical 
dressings should be of the same quality as that which the 
dental surgeons employ in taking casts for teeth — that is, 
the extra calcined variety. If moist or of inferior quality, 
it will not set rapidly or firmly, and will fail to give suffi- 
cient fixation to the dressing. 

The plaster-of-Paris dressing may be applied in several 
ways, either by covering the part to be enclosed with some 
loose fabric, and rubbing the moist plaster into it, alter- 
nating the layers of the fabric with layers of moist plaster, 
or it may be applied by means of a roller which has been 
prepared by incorporating plaster-of-Paris in its meshes. 

To apply a plaster-of-Paris dressing according to the 
first method, the part to be enclosed — the leg, for instance 
— should first be covered by a neatly applied flannel ban- 
dage or a muslin bandage, which has been shrunken by 
being washed ; new muslin is not satisfactory as a primary 
application to a limb in applying a plaster-of-Paris dress- 
ing, as the moisture from the plaster wets it and causes it 
to shrink, so that it may exert injurious pressure after the 
bandage becomes dry. 

The limb having been covered by the bandage, and any 
bony prominences such as the malleoli having been padded 
with small wads of cotton to prevent undue pressure upon 
them, the part is next covered by a layer of turns of a 
crinoline bandage or by strips of cheese-cloth or any other 
loose material. A small quantity of plaster-of-Paris is 
next mixed with water until it has the consistence of thick 
cream, when it is smeared evenly over the whole surface 
of the previously applied bandage. Another layer of the 
bandage or of strips is next applied, and the plaster is 
smeared over this in the same manner, and so alternate 
layers of plaster-of-Paris and bandage are applied until a 
casing of the desired thickness is obtained. If the plaster- 
of-Paris of the quality previously described be used, it 
will set or become hard in a few minutes. 

The most convenient method of applying the plaster-of- 



102 SPECIAL BANDAGES. 

Paris dressing is that employed by Prof. Sayre, which con- 
sists in the use of bandages which have been previously 
prepared with plaster-of- Paris ; these are moistened and 
applied while moist to the part to be encased. 

Preparation of the Plaster-of-Paris Bandage. 

These bandages are prepared by taking cheese-cloth, 
mosquito-netting, or crinoline, which latter is by far the 
best fabric, and cutting or tearing it into strips two and a 
half to three inches in width and five yards in length. 
These are laid on a table, and plaster-of-Paris of the 
quality before mentioned is dusted over them and rubbed 
into the meshes of the fabric; the material when impreg- 
nated with plaster is loosely rolled into a cylinder, and 
these bandages when prepared should be placed in air- 
tight jars or tin cans until required. 

Bandages thus prepared, which have been exposed to 
the air or have been kept for a long time, are not apt to 
set well when applied ; but if such bandages are placed in 
a hot oven and baked for half an hour before being used, 
they will be found to set as satisfactorily as those freshly 
prepared. 

These bandages may be prepared by a machine made 
for this purpose, but I do not think that they are apt to 
have the plaster as evenly distributed through them, and 
therefore are not as satisfactory, as those prepared by 
hand. 

Application of the Plaster-of-Paris Bandage. 

Before applying this dressing, the part to be encased — 
the leg, for instance — should be covered by a flannel roller, 
the bony prominences being protected by pads of cotton, 
or a closely fitting stocking may be applied to the part. 

The bandage should be dipped in warm water and kept 
covered for a few minutes ; it may be squeezed with the 
hand, and as soon as bubbles of air cease to escape it is a 



APPLICATION OF PLASTEB-OF-PABIS BANDAGE. 103 

sign that it is thoroughly soaked and is ready for appli- 
cation. 

On removing it from the water the excess of water 
should be squeezed out by the hand, and the bandage 
should then be evenly applied to the limb with just enough 
firmness to make it fit the part nicely, and as few reverses 
as possible should be made. A sufficient number of ban- 
dages are applied to make a dressing as firm as may be 
required; three rollers of the above dimensions are usually 
quite ample for a dressing for the leg, and when the last 
roller has been applied some dry plaster should be moist- 

Fig. 87. 




Leg encased in plaster-of-Paris dressing. 

ened with water until it has the consistence of thick cream, 
and it should be rubbed evenly over the surface of the 
bandage to give it a finish. (Fig. 87.) If a good quality 
of plaster has been used, the bandage should be quite firm 
in from ten to fifteen minutes, but the patient should not 
for a few hours be allowed to put any weight upon the 
bandage. 

An equally firm bandage may be applied with the use 
of a less number of bandages, if the surgeon rubs over the 
surface of each layer of bandage applied a little moist 
plaster, then applying another layer and repeating the 



104 SPECIAL BANDAGES. 

same procedure ; finishing the dressing by an external 
coating of moist plaster, as above described. 

In applying these dressings a fewer number of bandages 
will be required if narrow strips of tin, zinc, or binder's 
board are incorporated in the layers of the bandage, which 
also increase the strength of the dressing. 

Interrupted Plaster-of-Paris Dressing. 

This form of plaster-of-Paris dressing is applied by first 
placing a short iron rod under the extremity some distance 
above and below the point at which the dressing is to be 
interrupted; this is fixed by a few turns of the plaster 
bandage above and below the portion of the limb which is 
to be left exposed ; stout wire is next bent into loops, the 

Fig. 88. 




Interrupted plaster-of-Paris dressing. (Stimson. ) 

extremities of which are incorporated in the subsequent 
turns of the plaster bandage ; three loops thus placed in 
addition to the posterior iron bar will usually make the 
dressing sufficiently firm. (Fig. 88.) A number of turns 
of the bandage are applied to firmly fix the loops and 
the limb is held in the desired position until the plaster 
has set. 



APPLICATION OF PLASTER-OF-PARIS JACKET. 105 



Application of the Plaster-of-Pams Jacket. 

The patient's body should be covered with a soft, closely 
fitting woven shirt without arms, but with shoulder-straps 
to hold it in position, or an ordinary woven undershirt 
may be employed ; one or two folded towels, or a pad of 

Fig. 89. 




Suspensory apparatus. 



cotton wrapped in a towel, are next placed over the ab- 
domen between the shirt and the skin — this is called, by 
Prof. Sayre, the dinner pad, and is intended to leave space 
for the distention of the abdomen after eating. Small 
pads of raw cotton may also be placed over the anterior 
iliac spines, and, in the case of females, a pad of cotton 



106 



SPECIAL BANDAGES. 



wrapped in a handkerchief may be placed over each 
mammary gland. 

The patient should next be suspended by the apparatus 
consisting of a collar and arm-pieces attached to a cross- 
bar (Fig. 89), which is attached by a cord and pulley to a 



Fig. 90. 




Patient suspended for application of plaster jacket. 



tripod. If this apparatus is not at hand, a very satis- 
factory substitute may be made by folding two towels into 
cravats and tying together the ends, so as to make two 
loops, one of which is placed in each axilla ; a bar of 
wood two and a half feet in length is next taken and the 
loops are secured to the ends of this by stout cords or 



APPLICATION OF PLASTER- OF-PABIS JACKET. 107 

handkerchiefs ; a Barton's bandage is next applied to the 
head, and a strip of bandage is passed under the turns 
which cross the vertex and is secured to the middle of 
the cross-bar. The bar is next suspended by a cord 
passed through a pulley or ring which may be attached 
to the sill of a door if the ordinary tripod cannot be 
obtained. 

The patient should be slowly raised by the apparatus 
until the toes only are in contact with the floor, and the 
extension should not be carried to the point which makes 
it uncomfortable to the patient. (Fig. 90.) The shirt 
should be drawn downward over the hips by an assistant 
and held in place until a few turns of the bandage have 
been applied. 

The plaster bandage having been soaked and squeezed, 
a turn should be made around the body above the pelvis, 
and it should then be carried downward below the iliac 
spines, and from this point it should be made to ascend 
gradually by spiral turns until it reaches the axillary line. 
The turns should be applied smoothly and not too tightly. 
After two or three layers of turns have been applied, the 
surgeon may rub some moist plaster upon their surface if 
he desires to use fewer bandages. These turns are repeated 
until a bandage of the desired thickness is applied, and 
the surface of the dressing may be finished by rubbing 
it over with moistened plaster. This jacket for a child 
will generally require the use of three or four bandages 
of the dimensions given ; for an adult, six to eight band- 
ages. 

The patient should be kept suspended until the bandage 
has set, usually from ten to fifteen minutes, and then should 
be carefully lifted so as not to bend the spine, and placed 
on his back upon a mattress, until the dressing becomes 
perfectly hardened. The dinner pad and mammary pads, 
if they have been used, should next be removed. In 
applying this dressing, strips of zinc or tin may be placed 
between the layers of bandage if it is desired to give more 
strength to the jacket. 



108 



SPECIAL BANDAGES. 



Fig. 91. 



Application of the Jury-mast by Means of 
Plaster-of-Paris. 

In disease of the spine involving the cervical or upper 
dorsal region the ordinary plaster-of- Paris jacket is not 
satisfactory, and in such cases the "jury-mast" is em- 
ployed in connection with the 
plaster jacket. In applying the 
"jury-mast" the same steps are 
taken in the preparation of the 
patient as in applying the plaster- 
of-Paris jacket, with the exception 
of extension, which need not be 
used. 

After three or four layers ot 
the plaster bandage have been 
applied to the body, an apparatus 
made of two bars of metal having 
two perforated strips of zinc at- 
tached to them a few inches apart, 
which partly encircle the body, is 
applied and held in position by 
turns of the plaster bandage. The 
perpendicular bars have at their 
upper part a slot, into which the 
lower end (Fig. 91) of the "jury- 
mast" fits, and is secured by a 
screw ; to the upper part of this 
is attached a movable cross-bar, 
to which are fastened the straps of the collar from which 
the head is suspended. 




Head-support and jury-mast. 



The Bavarian Dressing. 

To apply this dressing, which is sometimes employed 
in the treatment of fractures, take two pieces of Canton 
flannel the length of the part to be enclosed, and more 
than wide enough to envelope its circumference. In 



THE BAVARIAN DRESSING. 



109 



applying it to the leg these pieces should be cut so as to 
correspond to the outline of the leg and posterior portion 
of the foot. 

These pieces should be placed one over the other and 
sewed together in the middle line, the seam corresponding 
to the back of the leg. The leg and foot are then placed 
upon this, and the inner layer of flannel is brought up in 
front of the leg and over the dorsum of the foot and made 
fast with pins. (Fig. 92.) Plaster-of-Paris is next mixed 
with water to form a paste, which is rubbed thickly 

Fig. 92. 




Bavarian dressing. 



and evenly over the flannel next to the limb until a 
sufficient thickness is obtained ; the outer layer of flannel 
is then brought up about the leg and moulded to its 
surface by the hands. A loosely applied roller may now 
be used to hold the dressing in place until the plaster 
has set. 

AVhen it is necessary to inspect the parts, the turns of 
the bandage are cut, and upon separating the layers of 
flannel the two halves can be turned aside, the seam at 
the back acting as a hinge. Upon reapplying the splints 
to the leg they may be retained in position by a roller or 
by one or two strips of bandage. 



110 SPECIAL BANDAGES. 

Moulded Plaster-splints. 

It is sometimes found difficult to apply the ordinary 
plaster dressings to parts irregular in their shape, and at 
the same time to have a splint which can be removed with 
ease. To accomplish this purpose moulded splints of 
plaster may be made by cutting a paper pattern of the 
part to be covered in, and then cutting pieces of crinoline 
to conform to this pattern • eight or ten pieces will usually 
form a splint of sufficient thickness. One of these pieces 
of crinoline is laid upon a table and dry plaster is rubbed 
into its meshes; another is laid upon this and plaster is 
applied to it in the same way, and so on until all the pieces 
have been placed in position, one over the other, with 
plaster rubbed well into the meshes. The dressing is then 
folded up and dipped into water, squeezed out, and moulded 
to the part and held in position, until it sets, by the turns 
of a bandage. The edges should overlap slightly, and in 
applying it a strip of waxed paper may be placed under 
the overlapping edge to prevent its adhesion to the dress- 
ing below, and thus facilitate its removal. Splints pre- 
pared in this way can be removed with ease, and are often 
of service in cases where it is desirable to inspect the parts 
frequently ; I have employed with advantage such splints 
in making fixation of the hip-joint in cases of coxalgia, 
and also for the same purpose in affections of other joints. 
The splints upon being reapplied are secured by a few 
strips of bandage, or by a roller-bandage. 

Trapping Plaster-of-Paris Bandages. 

In applying the plaster-of-Paris dressing to a part where 
there is a wound which is covered by the plaster-bandage, 
it is well to make some provision whereby the plaster- 
dressing over the site of the wound may be cut away, 
making a trap or window through which the wound may 
be inspected or dressed, if necessary. (Fig. 93.) To 
accomplish this, before applying the plaster-bandage, a 



REMOVAL OF PLASTER- OF- PARIS FROM HANDS. HI 

compress of lint or gauze should be placed over the wound, 
which, when the dressing is completed, forms a projection 
on its surface, indicating the position of the wound, and 
also allows the surgeon to cut away the dressing without 
injuring the skin below. These traps may be cut out after 
the bandage has partially set, or after it has become hard. 

Fig. 93. 




Plaster-of-Paris bandage trapped. (Esmaech.) 

In applying the plaster-of- Paris dressing in cases of com- 
pound fracture and after osteotomy, I always make pro- 
vision for trapping of the bandage if it should become 
necessary, although in the vast majority of cases it does 
not have to be done. 



Removing Plaster-of-Paris from the Hands. 



One objection to the use of plaster-of- Paris dressings is 
the difficulty of removing it from the hands of the surgeon, 
and the harsh condition in which the skin is left after its 
removal. If, however, the hands are washed in a solu- 
tion of carbonate of sodium — a tablespoonful to a basin of 
water — the plaster will be readily removed and the skin 
will be left in a soft and comfortable condition. 



112 



SPECIAL BANDAGES. 



Removal of the Plaster-of-Paris Bandage. 

The removal of the plaster-bandage is sometimes a 
matter of difficulty, particularly if it has to be removed 
before the parts below it are consolidated, as it may dis- 
arrange them and cause the patient pain if it is not 
accomplished without much force. 

Fig. 94. 




Cutting plaster-bandage upon lead strip. 

When the bandage is applied to get a cast of a part, or 
in the treatment of fractures where it may be necessary to 
remove the bandage in a few days to inspect the parts, 
a strip of sheet-lead one-half an inch in width is first 
placed over the flannel bandage, and is allowed to project 
at each end beyond the dressing ; the plaster can then be 
readily cut through upon this strip with a knife without 
injury to the parts below. (Fig. 94.) As soon as the 
bandage has become firm, the lead strip is removed by 
traction upon one end of it, and if the bandage has been 
entirely divided it can be removed at any time without 
difficulty. 

It may also be removed by means of a saw devised for 



USES OF PLASTER-OF-PARIS DRESSINGS. 113 

this purpose (Fig. 95), or by strong cutting-shears of 
various kinds (Fig. 96) ; or a line may be painted over 
the dressing with hydrochloric acid or vinegar, which 
softens the plaster so that it can readily be cut through 



Fig. 95. 




Hunter's saw for removing plaster-bandages. 

with a knife. Dr. William B. Hopkins has devised a 
vertebrated metal chain which is applied to the part before 
the plaster is applied and removed when the bandage has 
set, leaving a hollow longitudinal ridge which can be cut 




Shears for cutting plaster-bandages. 

through or divided with a rasp. The use of the saw or 
shears is, I think, most satisfactory in removing these 
dressings. They should be used carefully, as the final 
layers of the bandage are divided, to avoid wounding the 
skin. 

Uses of Plaster-of-Paris Dressings. 

These dressings are employed to secure fixation, as pri- 
mary or secondary dressings in the treatment of fractures, 
and for a like purpose in injuries and diseases of the joints. 
They are also largely used in the treatment of diseases 
and deformities of the spinal column, and will also be 
found most satisfactory applications after osteotomy and 
tenotomy, to secure immobility and hold the parts in their 



114 SPECIAL BANDAGES. 

corrected positions; when employed in the dressing of 
cases after tenotomy, they are generally used for a few 
weeks until the proper mechanical apparatus is applied. 

The Starched Bandage. 

To apply this bandage starch is first mixed with cold 
water until a thick, creamy mixture results ; to this is 
added boiling water until a clear mucilaginous liquid is 
produced ; if too thin, it can be made thicker by heating it 
upon a stove. The part to be dressed is first covered with 
a flannel roller, and over this a few layers of a cheese-cloth 
or crinoline bandage, which has been shrunken, are ap- 
plied; the starch is then smeared or rubbed with the hand 
evenly into the meshes of the material, and the part is 
again covered with a layer of turns of the bandage, and 
the starch is again applied : this manipulation is continued 
until a dressing of the desired thickness is produced. 
Strips of pasteboard may be applied between the layers 
of the bandage to give additional strength to the dressing, 
if desired. 

It requires from twenty-four to thirty-six hours for the 
starched bandage to become dry and thoroughly set. It 
may be removed in the same way in which the plaster- 
of-Paris dressing is removed. 

Use. — Before the introduction of the plaster-of-Paris 
dressing it was formerly much employed in the treatment 
of fractures and in injuries of the joints. It may be used 
in such cases, but possesses no advantage over the former 
dressing and has the disadvantage of setting much less 
promptly. 

GUM-AND-CHALK BANDAGE. 

In applying this dressing equal parts of powdered gum- 
arabic and precipitated chalk are mixed with boiling water 
until a mass of the consistence of cream results. This is 
applied to the cheese-cloth or crinoline bandage in the 
same manner as is the starch in the application of the 



THE PARAFFIN-BAND A GE. 115 

starched bandage ; it has the advantage over the latter 
dressing of setting more promptly, five or six hours only 
being required for it to become hard. It may be employed 
for the same purposes as the starched or plaster-of- Paris 
bandage. 

Silicate of Potassium or Sodium Bandage. 

In applying this bandage, after a flannel-roller and 
several layers of a cheese-cloth or crinoline bandage have 
been applied to the part, the surface of the latter is coated 
with silicate of sodium or potassium applied by means of 
a brush, then a second layer of bandage is applied and 
treated in the same manner, and this manipulation is con- 
tinued until a bandage of the desired thickness is pro- 
duced. It requires twenty-four hours for this dressing 
to become firm. As it is irksome for a patient to keep a 
part quiet while the silicate bandage is becoming hard, I 
often cover it as soon as applied with a layer of tissue 
paper and apply over it a light plaster- of-Paris bandage, 
which becomes hard in a few minutes ; this is removed at 
the end of twenty-four hours, when the silicate bandage 
is hard. In removing the silicate bandage it may be first 
softened by soaking it in warm water, and then it can be 
readily cut with scissors. 

In applying either the starched bandage or the silicate 
of potassium bandage care should be taken to use cheese- 
cloth or crinoline which has been shrunken by being 
moistened and allowed to dry before being employed ; 
otherwise dangerous compression of the part may occur if 
the bandage has been firmly applied and shrinks after its 
application. 

The Paraffin-bandage. 

Paraffin, which melts at from 105° to 120° F., is used 
in the application of this bandage. The limb being 
covered by a flannel-roller, a vessel containing paraffin is 
placed in a basin of boiling water. As the roller, w r hich 



116 SPECIAL BANDAGES. 

may be either of flannel, cheese-cloth, or crinoline, is 
unwound it is passed through the melted paraffin and 
applied to the part, and the turns are repeated until a 
dressing of sufficient thickness results, and the surface 
may be brushed over with melted paraffin. This dressing 
sets very rapidly, being quite firm in from five to ten 
minutes. 

It possesses the advantage of the other fixed dressings 
in that it does not absorb discharges and become offensive, 
and for this reason it was formerly recommended in the 
treatment of compound fractures. 

Glue or Glue and Oxide of Zinc Bandage. 

Glue or glue combined with oxide of zinc has been em- 
ployed in the preparation of fixed dressings, but possesses 
no advantages over those previously mentioned. 

RAw r -HiDE on Leather Splints or Dressings. 

In moulding raw-hide or leather splints it is necessary, 
first, to apply a plaster-of-Paris bandage to the part to 
which the raw-hide splint is to be fitted ; and as soon as 
the plaster has set it is removed, and a solid plaster cast 
is next made by pouring liquid plaster-of-Paris into this 
mould. When this has become dry a piece of raw-hide, 
which has been soaked for a time in warm water, is 
moulded to the cast and held firmly in contact with it 
by tacks or a bandage until it has become perfectly dry. 
It is then removed, and its surface is covered with 
several coats of shellac, to prevent its absorbing moisture 
from the skin when applied, and changing its shape. 
Eyelets or hooks are fastened to the edges of the splint, 
through which strings are passed to secure the splint in 
place. 

Made in this manner raw-hide splints fit the part very 
accurately, and constitute a very satisfactory dressing for 
cases of joint-disease, and in the form of leather-jackets 



BINDER'S BOARD OR PASTEBOARD SPLINTS. 117 



Fig. 97. 



are often employed in the treatment of disease of the spine 
in place of the plaster-of-Paris jacket. (Fig. 97.) 

In the treatment of high dorsal or cervical caries a 
leather-splint in two sections, which 
rests upon the shoulders and sup- 
ports the head, is often used with 
good results. (Fig.98.) 

Binder's Board or Pasteboard 
Splints. 

This material, which can be ob- 
tained in sheets of different thick- 
ness, is frequently employed for 
the manufacture of splints. In 

Fig. 98. 





Leather-jacket with jury- 
mast. 



Leather-splint for cervical caries. 
(Owen.) 



moulding these splints a portion of the board of the 
requisite size and thickness is dipped in boiling water 
for a short time, and when it has become softened it is 
removed and allowed to cool ; a thick layer of cotton- 
batting is next applied over it, and it is then moulded 
to the part and held firmly in place by the turns of a 
roller-bandage ; in a few hours it becomes dry and hard. 

This material, from its cheapness and the ease with 
which it is obtained, is frequently employed to mould 

6* 



118 SPECIAL BANDAGES. 

splints for the treatment of fractures, especially in chil- 
dren, and for the fixation of joints in the treatment of 
acute and chronic joint affections. A moulded pasteboard- 
splint is also often employed to fix the ends of the bones 
after the excision of a joint. 

Porous Felt-splints. 

This material is also employed for the manufacture of 
splints, and is applied by dipping the material in hot 
water and then moulding it to the part ; as it dries it 
becomes hard. 

Hatter's Felt Splints. 

Hatter's felt is also frequently employed for the manu- 
facture of splints or dressings. It is softened by dipping 
it in boiling water or heating it in the flame of an alcohol 
lamp, and when soft and pliable it is moulded to the part, 
and as it cools it again becomes hard. 

These splints are employed for the same purposes as 
those made of plaster-of-Paris, leather, or pasteboard. 



PAET II. 

MINOR SURGERY. 



Theory of Asepsis and Antisepsis in Wound 
Treatment. 

The term Asepsis, applied to a wound, implies that it 
is free from those vegetable parasites or micro-organisms 
whose presence sets up fermentative changes, accompanied 
by suppuration and constitutional disturbance. 

Antisepsis, on the other hand, has reference to the means 
employed to bring about the destruction of micro-organisms 
which may be present in the wound or upon the instru- 
ments, dressings, or hands of the surgeon, and which, if 
not destroyed or rendered inert, will set up fermentative 
changes in the wound. 

It has long been a well-recognized fact that albuminoid 
substances, such as dead animal tissue, blood, or blood- 
serum, will, when exposed to moisture, warmth, and the 
presence of certain living organisms or fungi, bacteria and 
micrococci, develop putrefactive changes ; and if these 
changes take place in the living body, there result certain 
constitutional disturbances known as symptomatic, inflam- 
matory, or septic fever. 

It was also recognized that these putrefactive changes 
in albuminoid substances could be avoided by their ex- 
posure to heat, cold, or by drying — any of these conditions 
being sufficient to destroy or arrest the development of 
the micrococci. 

Sepsis in the living organism is due to the entrance and 



120 MINOR SURGERY. 

multiplication of microbes, or the absorption of their 
products, and is characterized by local inflammation of 
the wound, grave constitutional disturbances, fever, dis- 
orders of the nervous system, and infection of the viscera. 
Microbic infection should be considered a disease-process 
which causes disastrous wound-complications, and differs 
materially from that process which attends the repair of 
injuries and the union of wounds which run an aseptic 
course. At the present time no surgeon should undertake 
the performance of an operation or the treatment of an 
open wound without having clearly impressed upon his 
mind the important part the pyogenic microbes may play 
in the subsequent course of the wound. It has been 
clearly proved that certain species of microbes caused su- 
puration and gangrene, that others cause inflammation, 
and that others produce ferments, and some form different 
substances known as ptomaines, toxins, toxalbumins, all 
of which exercise a virulent influence upon the living 
organism. It is an unquestionable fact that pyogenic 
microbes under different conditions can produce a series 
of different diseases, for it is now generally accepted that 
Fehleisen\s streptococcus erysipelatis is identical with 
the streptococcus pyogenes, which is recognized as the 
cause of many different inflammatory .affections. The 
theory has been advanced by Reger to account for this, 
that all the so-called pus-diseases are simply a local ex- 
pression of a general infection caused by many different 
micro-organisms. It is scarcely possible that any wound 
is entirely free from germs, when we take into considera- 
tion their almost universal presence, so it may be assumed 
that infection does not necessarily depend upon the pres- 
ence of a few microbes, but rather upon the quantity and 
quality of the germs which are present in the wound It 
has been shown by Cheyne that the number of bacteria 
entering the tissues is an important factor in producing 
suppuration or septic infection, for we know that healthy 
tissues will destroy or remove an innumerable number of 
germs ; suppuration or infection occurring only when the 
tissues are overwhelmed by the number of organisms, or 



THEORY OF ASEPSIS AND ANTISEPSIS. 121 

their power of resistance is diminished by injury or disease. 
The micro-organisms which set up fermentative and putre- 
factive changes in animal tissues exist in great variety, but 
those which are of most interest to the surgeon belong to 
the cocci and bacilli. 

Staphylococcus Pyogenes Aureus. — This organism, which 
is spherical and apt to form clusters, has been shown to be 
the most common cause of acute suppuration in living 
human tissues. These microbes are found in great num- 
bers upon the surface of the body and in the superficial 
layers of the skin, especially in the region of the axilla, 
umbilicus, perineum, and finger-nails ; they are also found 
upon the mucous membrane of the mouth, pharynx, and 
alimentary canal. 

Staphylococcus Pyogenes Albus and Citreus. — These are 
micro-organisms which frequently exist in connection 
with the previously mentioned organisms. All these varie- 
ties of staphylococci are found in circumscribed suppura- 
tion, such as acute abscesses, adenitis and osteo-myelitis. 

Streptococcus Pyogenes. — This is one of the most impor- 
tant of the pyogenic cocci which extends rapidly along the 
lymph spaces and lymphatics, and by rapid infiltration 
causes gangrene. This micro-organism is found in the 
vagina, urethra, and nasal cavities. It produces pro- 
gressive suppurations, such as phlegmonous cellulitis and 
erysipelas, and is morphologically similar to the strepto- 
coccus erysipelatis. 

Bacillus Pyogenes. — This is an organism which is found 
in blue or green pus. 

Bacillus Pyogenes Fcetidus. — This is a short, rod-like 
organism, which is said to exist only in the human body, 
and is found in abscesses containing foul-smelling pus, in 
the region of the anus, brain, and other parts of the body. 

Many other organisms exist which are of interest to the 
surgeon, such as micrococcus gonorrhoea, bacillus tubercu* 
losis, bacillus of tetanus, bacillus of malignant oedema, 
bacillus mallei, and bacillus anthracis. 

In w r ounds the result of accident or made by the 
surgeon all the conditions are most favorable for the 



122 MINOR SURGERY. 

entrance and development of these organisms. The 
serum and blood and the dead or partially devitalized 
cells of the various tissues are most favorable media for 
their growth. We have present also warmth and moist- 
ure, and in the air coming in contact with the wound we 
have vast quantities of dust laden with spores, which 
under these favoring conditions develop into the organ- 
isms before mentioned, which rapidly set up fermetative 
processes known as decomposition. 

The products of this decomposition, carried into the 
circulation by the lymphatics and veins, set up local 
changes in the shape of inflammation and at the same time 
give rise to systemic disturbances which we recognize as 
septic fever. 

Modern wound-treatment aims at the prevention of 
decomposition and suppuration, and accomplishes this 
purpose by having the wound kept aseptic, by perfect 
cleanliness of the region of the wound, the hands and 
instruments of the surgeon, and by not exposing the wound 
to an atmosphere which contains dust ; as the latter con- 
dition is difficult to obtain we secure the destruction of the 
micro-organisms which may be present by heat, as seen in 
the use of the actual cautery or by chemical sterilization, 
which is accomplished by the use of germicides. 

Surgical Cleanliness. 

Surgical cleanliness may be obtained by following either 
the aseptic or the antiseptic method. 

Although at the present time these two methods are to 
a certain extent combined, that is, it is impossible to be 
strictly aseptic without employing means of disinfection, 
that is, employing antiseptic methods to a certain extent, 
the antiseptic method of wound- treatment was first intro- 
duced, and produced a revolution in surgical practice, but at 
the present time, recognizing that certain evils have arisen 
from the use of antiseptics, and that equally good or better 
results may be obtained without bringing antiseptic sub- 
stances directly in contact with wounds, the aseptic method 



SURGICAL CLEANLINESS. 123 

has been widely and successfully adopted, and to day the 
weight of surgical opinion is decidedly in favor of the 
latter method. 

Antiseptic Method. 

In the antiseptic method the sterilization of the field of 
operation, the hands of the surgeon and assistants, the in- 
struments, ligatures, sponges, and sutures, is accomplished 
by the use of germicidal solutions, and in addition the 
wound is irrigated constantly during the operation by ger- 
micidal solutions, and is afterward covered with dressings 
impregnated with germicidal substances. 

Aseptic Method. 

In the aseptic method the field of operation, the hands 
of the surgeon and his assistants, the instruments, ligatures, 
sponges, and sutures are sterilized by the use of germicidal 
solutions and heat, and after this has been accomplished, 
relying upon the completeness of the sterilization, no anti- 
septic substances are brought in contact with the wound, 
sterilized water being used if it is necessary to flush the 
wound, and the dressings employed are only those which 
have been sterilized by moist or dry heat. 

The disadvantages of the antiseptic method in wound- 
treatment which have caused it to be largely succeeded by 
the aseptic method are, first, that recent investigations have 
shown that many of the germicidal substances have not 
the disinfecting power which has long been attributed to 
them ; second, that antiseptic substances to be active as 
germicides may cause irritation of the surface of the wound, 
interfering with its repair, and are apt to cause very free 
oozing of serum, which necessitates the use of drainage, 
and makes the frequent dressing of the wound necessary ; 
many antiseptic substances also produce marked toxic 
effects upon the patient, and often cause very severe irrita- 
tion of the skin in contact with the dressings. 

The advantages of the aseptic method may be briefly 
stated, that the method is applicable in all parts of the 



124 MINOR SURGERY. 

body ; wounds treated by this method heal more promptly 
and do not so often require dressing ; there is no risk of 
toxic effects, and no irritation of the skin by the dressings ; 
the dressings are also less expensive. Dry sterilized dress- 
ings are efficient as dressings to produce absorption, and 
at the same time the dryness may be a factor in the 
destruction of germs, for exposing bacteria to dryness 
deprives them of moisture, which is one of the conditions 
necessary for their existence. It may, therefore, be laid 
down as a general rule that the aseptic method is to be 
preferred to the antiseptic method when and wherever it 
is possible. 

Agents Employed to Secure Asepsis. 

A great variety of agents possessing more or less germi- 
cidal properties have been at different times employed in 
the practice of aseptic or antiseptic surgery ; those most 
employed at the present time are heat, bichloride of mer- 
cury, carbolic acid, iodoform, beta-naphtol, chloride of 
zinc, peroxide of hydrogen, creolin, permanganate of potas- 
sium, pyoktanin and boric acid, the double cyanide of 
mercury and zinc, and aristol. 

Heat. 

The most reliable and universally available agent for 
the destruction of pyogenic organisms is heat, either dry 
or moist ; many forms of bacteria are rendered inert at a 
temperature of 140° F., and none can withstand the appli- 
cation of moist heat at a temperature of 212° F. continued 
for a short time. Spores which will resist the action of 
powerful germicides for a considerable time are destroyed 
by boiling for a few minutes. As moist heat is the most 
efficient sterilizer, it should be preferred, and can always 
be made use of for this purpose by boiling the instruments 
and dressings for a few minutes, and if for any reason it is 
thought advisable to employ dry heat as a sterilizer, this 
may be made use of by baking the instruments or dress- 



BICHLORIDE OF MERCURY. 125 

ings in a hot oven. The same results, of course, may be 
obtained by the use of one of the various dry or moist 
sterilizers. 

Bichloride of Mercury. 

This is employed as an antiseptic in watery solution, 
varying in strength from 1 : 500 to 1 : 10,000. 

The solution 1 : 500 to 1 : 1000 is used only for the 
irrigation and disinfection of the hands and skin ; for the 
irrigation of wounds, a solution of 1 : 2000 is generally 
employed. In using the bichloride solution in operations 
upon children, I am in the habit of using a solution of 
1 in 4000, and I find that it produces less irritation of the 
skin and is equally efficient as a germicide. Where con- 
tinuous irrigation is kept up or where it is employed in 
large cavities, a still weaker solution, 1 : 5000 to 1 : 10,000 
should be employed. 

In using these solutions the surgeon should watch the 
patient carefully for symptoms of poisoning due to the 
absorption of the bichloride of mercury ; the symptoms 
denoting this are vomiting, fetid breath, salivation, in- 
flammation of the gums, diarrhoea, blood-stained stools, 
and bleeding from the mouth and nose. 

In preparing the solutions of bichloride of mercury for 
use, it will be found convenient to have a concentrated 
solution of the salt in alcohol, one part of the bichloride 
of mercury to ten parts of alcohol ; this can be kept in a 
well-stoppered bottle, and to this should be added one tea- 
spoonful of common salt, which prevents the disintegration 
of the mercuric compound. One teaspoonful of this 
solution added to one quart of water makes a 1 : 1500 
solution. 

A ten per cent, bichloride solution may be made as 
follows : 

Bichloride of mercury 2 parts. 

Sodium chloride 1 part. 

Dilute acetic acid 1 " 

Water 16 parts. 

By adding water in an appropriate quantity, a 1 : 1000 or 1 : 2000 solution can 
be made. 



126 MINOR SURGERY. 

Or the solution may be prepared with tartaric acid in 
the proportion of five parts of the acid to one part of the 
bichloride of mercury, the following formula being em- 
ployed : 

Hydrarg. chlor. corrosiv grs. xv. 

Ac. tartaric grs. lxxv. 

Aquae dest Oij. 

Pellets containing a definite amount of bichloride of 
mercury compounded with a few grains of common salt 
or muriate of ammonia, which, when dissolved in a definite 
quantity of water, make a solution of 1 : 1000 or 1 : 2000, 
will also be found very convenient for the preparation of 
solutions. 

These bichloride or sublimate solutions are also em- 
ployed to sterilize the gauze and cotton which are largely 
employed in antiseptic dressings. 

Carbolic Acid. 

This drug is employed in solutions of 1 : 20 or 1 : 40. 
The stronger solution, 1 : 20, is usually employed to 
sterilize the instruments, the latter being allowed to 
remain in this solution for thirty minutes before being 
used. As a carbolic solution of this strength benumbs 
and cracks the skin of the hands of the operator, it should 
be diluted just before the instruments are required, by 
adding an equal quantity of water, making it a 1 : 40 
solution. 

The 1 : 40 solution is used for the irrigation of wounds 
and the washing of sponges. Carbolic acid is also em- 
ployed in the preparation of gauze. A ready method of 
making a 5 per cent, carbolic solution is to add one table- 
spoonful of carbolic acid to one pint of hot water. 

In using carbolic acid solutions continuously the surgeon 
should be on the watch for the symptoms of poisoning, 
which will show itself by dark-colored urine, headache, 
dizziness, vomiting, and in severe cases bloody diarrhoea, 
hemoglobinuria, and death from collapse. Carbolic acid 
solutions should be used with great caution in young 



IODOFORM. 127 

children, as they seem to be more susceptible than adults 
to the constitutional effects of this drug. I have seen 
the use of quite dilute solutions produce the characteristic 
symptoms of poisoning in such patients. 

Iodoform. 

Iodoform is one of the most valuable antiseptic drugs 
we possess, although it has been shown by experimental 
research to possess little germicidal action ; but in spite of 
this fact clinical experience has proved that it possesses 
powerful antiseptic properties, due not to the destruction 
of germs, but to its undergoing a decomposition in their 
presence, and thus rendering the ptomaines which have 
resulted from the germ-growth inert. Iodoform may be 
rendered absolutely sterile by washing it in a 1 : 1000 
bichloride solution, which destroys all micro-organisms ; 
it should then be dried, and kept for use in closely stop- 
pered bottles : or it may be exposed to dry heat in a ster- 
ilizer or oven, which will accomplish the same purpose. 

Iodoform is very extensively employed as an application 
to wounds ; it is especially useful as a dressing to infected 
wounds and to tubercular or syphilitic ulcers. It is also 
employed in the preparation of iodoform-gauze, and may 
be combined with collodion to form iodoform- collodion, 
which is a useful dressing in superficial wounds : 

Iodoform -. grs. xlviij. 

Collodion 5j. 

An ethereal solution of iodoform (iodoform grs. xv, 
ether §j) is also used as an application to chronic ulcers. 

An emulsion of iodoform in glycerin (iodoform 5j> 
glycerin 5x), or an emulsion of iodoform made by boiling 
iodoform 5j, olive oil 5x, is much employed at the present 
time as an injection in the treatment of chronic abscesses 
and tubercular disease of the joints. 

Elderly persons are more prone to the toxic action of 
iodoform than young persons These symptoms are mani- 
fested by sleeplessness, debility, headache, delirium, and 
death may result from meningitis or cardiac depression. 



128 MINOR SURGERY. 



Beta-naphtol. 



Beta-naphtol, in a 1 : 2500 solution, is employed for 
much the same purposes as the bichloride of mercury solu- 
tion ; it is not, however, so powerful a germicide. It is 
employed in irrigating large cavities because it is not a 
poisonous agent, but is especially useful as a bath for 
instruments, as it does not corrode them, as does the sub- 
limate solution. It also possesses the advantage over a 
carbolic acid solution of not irritating the skin of the 
surgeon's hands. 

Chloride of Zinc. 

Chloride of zinc, in a solution of 30 to 40 grains to 
water fgj, is a very powerful antiseptic. When employed 
upon raw surfaces it produces marked blanching of the 
tissues ; it is especially useful in wounds which are in- 
fected or which have been exposed to infection. I have 
found it by all means the best application to the poisoned 
wounds which are received in dissecting dead bodies and 
in operating. In such cases the whole cavity or surface 
of the wound should be washed with a 30-grain solution 
of the chloride of zinc, and then the wound should be 
dressed with a bichloride dressing. 

SuLPHO-CARBOLATE OF ZlNC. 

This drug has been found to possess more decided anti- 
septic properties than the chloride of zinc, and is much 
less irritating. It may be used in the same strength and 
for the same purposes as the former drug. 

Aluminum Aceticum. 

This substance is prepared by adding sugar of lead, 25 
parts, to a solution of 5 parts of alum to 500 parts of 
distilled water. It has decided germicidal qualities and 



KREOLIN OR CREOLIN. 129 

is employed for irrigation, or on moist dressings when 
carbolic or bichloride solutions cannot be used. 



Peroxide of Hydrogen. 

This drug is employed in what is known as a 1 5- volum 
solution, which may be diluted from 10 per cent, upward 
or used in full strength. It is employed in the steriliza- 
tion of sinuses or suppurating cavities, such, for instance, 
as often result from diseases of or operations upon bone. 
It seems to have a direct action upon pus-generation by 
destroying the micro-organisms of pus. It is injected 
into sinuses and cavities by means of a syringe, or may 
be applied to open wounds in the form of a spray ; its 
activity is shown by the escape of bubbles of air, and it 
should be used as long as these continue to escape. 

Pyrozone possesses the same qualities as the peroxide of 
hydrogen, apparently to a somewhat higher degree, and 
is used for the same purposes. 



Kreolin or Creolin. 

This substance is obtained from English coal by dry 
distillation, and has been found to possess powerful germi- 
cidal properties ; it is non-irritating and practically non- 
toxic. It is insoluble in water, but forms an emulsion 
with it which possesses marked antiseptic properties. It 
may be employed for the same purposes as carbolic acid, 
and has the advantage over the latter drug that it is not 
irritating to the skin, and is almost devoid of toxic 
properties. 

It is used in an emulsion, in strength from two to five 
per cent., and is employed in the irrigation of large wounds 
or cavities of the body, and has been most favorably 
recommended in gynecological practice. As a bath for 
instruments, to render them sterile during operations, it is 
useful, but the opacity of the emulsion makes it difficult 
to find the instruments and interferes with its efficiency. 



130 MINOR SURGERY. 



Boric Acid. 



This drug has not very marked antiseptic qualities, but 
is unirritating even in saturated solutions. It is frequently 
employed in a 5 to 30 per cent, solution to cleanse and 
disinfect mucous surfaces and large cavities. It is often 
employed to wash out the bladder before the operation for 
the removal of calculi or growths from that organ. 

In the dressing of superficial wounds, or in wounds in 
which the bichloride or carbolic acid dressings produce 
irritation, an ointment of boric acid, made by taking boric 
acid 1 part, and vaseline 5 parts, will be found very 
satisfactory. 

BORO-SALICYLIC LOTION. 

This lotion is prepared by adding 2 parts of salicylic 
acid and 12 parts of boric acid to 1000 parts of hot water. 
This forms a very bland solution, which can be used where 
there is danger in using bichloride or carbolic solutions — 
as, for instance, in the bladder or peritoneal cavity. 

Permanganate of Potassium. 

This drug, owing to its rapid absorption of oxygeu, 
acts as an antiseptic, and is often employed for the disin- 
fection of foul wounds and ulcers. It is also employed 
in solution for washing the operator's hands and for the 
washing of sponges. It is practically non-irritating, and 
may be used in quite concentrated solutions, but is usually 
employed in the following solution : Permanganate of 
potash 5j ? water f§j. One fluid drachm of this solution 
to a pint of water makes a 1 : 1000 solution. 

Pyoktanin. 

Methyl-violet, known in commerce under the name of 
pyoktanin, has been recommended as a drug possessing 
marked antiseptic powers. It is said to prevent suppura- 



DOUBLE CYANIDE OF MERCURY AND ZINC. 131 

tion by destroying the organisms which are active in its 
production, and which have an affinity for and are 
killed by aniline colors. It has been claimed that it 
sterilizes the pus of suppurating wounds and ulcers, and 
it has been recommended as an injection in the treatment 
of large suppurating cavities for this purpose, as it is 
practically non-poisonous. 

It is employed in a solution of a strength of 1 : 1000 or 
1 : 2000, and for the sterilization of surgical instruments 
a 1 : 10,000 solution may be employed. When employed 
as a means of irrigating wounds, it should be used until 
the tissues are of a deep-blue color. Eecent investigations 
have shown that it is, as a germicide, much less reliable 
than bichloride of mercury. 

Aeistol. 

Aristol, which is a compound of iodine and thymol, pos- 
sesses germicidal properties, and has been introduced as a 
substitute for iodoform. It has the advantage over iodo- 
form of not being poisonous and is also without disagree- 
able odor. It may be employed for the same purposes as 
iodoform, and it seems to be particularly useful as a dress- 
ing to chronic and specific ulcers. 

Iodol. 

This drug possesses antiseptic properties and is employed 
for much the same purposes as iodoform and aristol, and 
has much less odor than the former; it is soluble in 
alcohol, ether, and oil, and may be employed in solution 
or used as a dry powder. 

It is used for the same purposes as iodoform, and is 
much employed as a local application in inflammatory and 
ulcerated conditions of the mucous membrane of the nose 
and throat. 

Double Cyanide of Mercury and Zinc. 

Cyanide of potassium, cyanide of mercury, and sulphate 
of zinc are mixed together in solution, in quantities pro- 



132 MINOR SURGERY. 

portioned to the atomic weights of 2KCy, HgCy 2 and 
ZnS0 4 + 7H 2 ; the cyanide of potassium and cyanide of 
mercury being dissolved together in one and a half ounces 
of water for every 100 grains of potassium cyanide, are 
added to the sulphate of zinc dissolved in three times that 
amount of water. The precipitate is collected and washed 
in two successive portions of water equal in quantity to 
that used for the solutions, that is, six ounces of water for 
every 100 grains of the potassium cyanide, to free the 
precipitate from the irritating salts associated with it in 
its formation. The precipitate being well washed, is next 
mixed with distilled water containing one part of hema- 
toxylin for every 100 parts of the cyanide salt ; this, when 
it precipitates the cyanide salt, changes its color to a pale 
bluish tint. 

Ammonia is next added in such a proportion to the 
mixture that one fluidrachm of the ammoniacal liquid 
shall correspond with one grain of hematoxylin, and the 
ammoniacal mixture is allowed to stand for three or four 
hours, when it is filtered and the dyed salt is drained and 
dried at a moderate heat, is next levigated, and may then 
be kept for any length of time until used. When employed 
for charging gauze it is mixed with a 1 : 4000 bichloride 
solution in the proportion of four pints of the solution to 
100 grains of the salt. 



Preparation of Materials Used in Aseptic Surgery 
and Dressings. 

Sponges. 

Sponges cannot be sterilized by boiling, which destroys 
them, so they have to be prepared by washing and by 
treatment with germicidal solutions ; they are prepared as 
follows : 

Sponges, while dry, should be beaten to free them from 
calcareous matter, then placed in a 1 5 per cent solution of 
hydrochloric acid for thirty minutes to dissolve any lime 



GAUZE PLEDGETS OR PADS. 133 

which may remain in them; they should then be removed 
from this solution and thoroughly washed. They should 
next be well washed with green or castile soap and warm 
water for a few minutes, and then thoroughly rinsed and 
placed in a 1 : 1000 bichloride solution or in a 5 per cent, 
carbolic solution in closely covered jars until required for 
use. 

Or, after beating the sponges to remove any sandy mat- 
ter, they may be placed for twenty-four hours in a solution 
of hydrochloric acid — hydrochloric acid §iv, water four 
pints — then removed and washed until free from acid, 
then steeped for half an hour in a solution of permanganate 
of potassium, 180 grains to six pints of water. Next wash 
them and place them in the following solution : hypo- 
sulphite of sodium, §x ; hydrochloric acid, f§v ; water, 
fSlxviij ; and allow them to remain in this solution for 
four hours ; remove them from this and place them in 
running water for six hours ; they should then be placed 
in jars and covered either by a 5 per cent, carbolic acid 
solution or a 1 : 1000 bichloride solution. The carbolic 
acid solution is better for keeping the sponges than the 
sublimate solution, as it does not decompose. 

They may be prepared also by beating and washing 
them, and then soaking them for twelve hours in a solu- 
tion of chlorinated soda — chlorinated soda 1 part, water 5 
parts. They are then removed, well rinsed, and placed 
in a 5 per cent, carbolic solution, or they may be placed 
in a moderately warm oven until thoroughly dry, and then 
placed in air-tight jars, if it is desired to keep them dry. 

It is better to use a cheaper grade of sponges, and to use 
them only once ; but if the same sponges are to be used 
again, they should be well washed in a solution of carbonate 
of soda, 1 ounce to the quart, and then placed in a 1 : 1000 
bichloride solution. 

Gauze Pledgets or Pads. 

Pads or pledgets of sterilized or sublimated gauze may 
be used in the place of sponges during operations, and in 

7 



134 MINOR SURGERY. 

preparing the gauze-pads, a piece of gauze composed of 
from sixteen to twenty layers is cut into pads of the desired 
size, and the layers in each pad are quilted together by a 
few stitches, and the edges should be loosely whipped with 
a thread to prevent the edges from fraying. The gauze- 
pledgets are prepared by cutting a piece of gauze composed 
of from twelve to sixteen layers in pieces six inches square, 
the four angles of these pieces are then brought together 
and tied by a thread or are secured together by a few 
stitches. 

The pads or pledgets are usually employed in a moist 
condition, and before being used should be sterilized by 
being placed in a 1 : 2000 bichloride solution or by boiling, 
and any excess of moisture should be squeezed from them 
before being brought in contact with the wound. 

Silk. 

Silk for sutures or ligatures, either the plaited silk or 
the Chinese twisted silk, should be sterilized by boiling 
for thirty minutes in a 5 per cent, solution of carbolic 
acid or water, then placed in stoppered bottles and covered 
with a 5 per cent, solution of carbolic acid or with abso- 
lute alcohol. 

SlLKWORM-GUT. 

Silkworm-gut is an excellent material for sutures, and 
is much easier to thread than the silk or catgut. A black 
iron-dyed silkworm-gut has recently been introduced, the 
use of which facilitates the finding of the sutures for re- 
moval. It may be kept dry in glass jars, or preserved in 
alcohol, and should be placed in a 5 per cent, carbolic 
solution for a few minutes before being used, as this 
renders it more supple. 

Catgut Ligatures or Sutures. 

In preparing catgut for ligatures or sutures, the ordinary 
catgut of the shops should be washed with castile soap and 



CATGUl LIGATURES OR SUTURES. 135 

water, and then should be placed in ether and allowed to 
remain for four or five hours, and upon being removed 
should be placed in 95 per cent, alcohol in a tightly stop- 
pered bottle. 

Before being used it should be soaked for a few minutes 
in a 1 : 20 carbolic solution. 

Von Bergmanns Method of Sterilizing Catgut. 

First sterilize the vessel by boiling water or dry heat. 
The catgut should then be loosely wound upon glass rods 
or spools and placed in the sterilized vessel, covered with 
ether, and allowed to remain for twenty-four hours. At 
the end of this time the ether should be poured off and 
the gut should be placed in the following solution : 

Bichloride of mercury ....... 10 parts. 

Alcohol (95 per cent.)* 800 «' 

Distilled water . 200 " 

Remove in twenty-four hours and place in a similar so- 
lution for twenty-four hours longer, then remove and place 
in alcohol if stiff catgut is required. If soft catgut is 
desired, add 20 per cent, of glycerin to the alcohol in 
which it is kept. 

Catgut Boiled in Alcohol. 

This is accomplished by placing the catgut in a strong 
glass bottle containing alcohol, which is corked, placed 
in hot water and boiled for fifteen minutes. The steriliza- 
tion of the catgut is usually complete after this process. 

Juniper Catgut. 

Catgut, varying in size from No. 0, which is very fine, 
to No. 4, which is quite thick, is placed in oil of juniper- 
berries for one week, and is then transferred to absolute 
alcohol, in which it should be kept until required for use. 

No. 1 catgut is the size usually employed for ligatures 
and sutures. 



136 MINOR SURGERY. 

Alcohol is the best material in which to preserve the 
catgut, as it keeps it firm and does not interfere with its 
flexibility, while both carbolic acid and bichloride solu- 
tions render it brittle and weak. 

Chromic Acid Catgut. 

The catgut is first washed in alcohol and placed in dne 
quart of a 5 per cent, solution of carbolic acid, containing 
30 grains of bichromate of potassium, and is allowed to 
remain for forty-eight hours. This immersion should be 
longer when large-sized varieties of catgut are used ; but 
for the sizes of catgut which are ordinarily used, this length 
of immersion will prepare the gut to resist the action of 
the living tissues for a week or more. Catgut thus pre- 
pared may be dried and placed in closely stoppered jars, 
or may be kept in alcohol. 

Catgut may also be prepared by soaking it in alcohol 
for a short time, and then placing it in the following 
solution for forty-eight hours : Chromic acid, 1 grain ; 
carbolic acid, 200 grains ; alcohol, 2 drachms ; water, 2J 
ounces. It is then removed and placed in glass jars for 
use. 

Before being used it should be soaked for thirty minutes 
in a 5 per cent, carbolic acid solution, or in a 1 : 1000 
bichloride solution. 

The chromic acid catgut is by far the best variety ot 
gut to use for sutures and for the ligation of the larger 
vessels in their continuity. 

Drainage-tubes. 

The drainage-tubes usually employed are prepared from 
rubber-tubing of different sizes perforated at short in- 
tervals ; the black rubber tubes are softer and more pliable 
than the red or white rubber tubes, and should be pre- 
ferred. (Fig. 99.) Drainage-tubes are also made of glass, 
straight or curved (Fig. 100), which are almost exclusively 
used in abdominal surgery, and also of decalcified bone. 



HORSEHAIR AND CATGUT FOR DRAINAGE. 137 

Drainage-tubes should be kept 111 a 5 per cent, solution of 
carbolic acid, or, if kept dry, they should be well washed, 



Fig. 99. 




Rubber drainage-tube. 



and may be sterilized by dipping them in boiling water 
for a few minutes, or should be placed in a carbolic or 
bichloride solution for thirty minutes before being used. 



Fig. 100. 




Glass drainage-tube. 



Horsehair and Catgut for Drainage. 

Cutgut as ordinarily prepared for ligatures may be used 
to secure drainage in small and superficial wounds ; a 



138 MINOR SURGERY. 

number of strands of catgut are placed in the bottom of 
the wound, and the end or ends are allowed to project 
from one or both extremities of the wound. 

Horsehair may be employed for the same purpose, a 
number of strands of the hair being placed in the wound 
in the same manner. Before being used it should be well 
washed with soap and water and then soaked in a 5 per 
cent, carbolic solution or 1 : 1000 bichloride solution for 
thirty minutes. 

Protective. 

Protective is employed to prevent the wound from being 
irritated by the antiseptic substances with which the gauze 
is impregnated or by its irregular surface. 

Various materials are employed as protectives, the 
principal requirement being that it is some tissue which 
can be readily rendered aseptic, and does not absorb any 
irritating materials from the dressings. 

The protective first employed by Mr. Lister, which is 
still generally used, is prepared by coating oiled silk with 
copal varnish, and when this is dry a mixture of 1 part 
of dextrine, 2 parts of powdered starch, and 16 parts of 
a 1 : 20 carbolic acid solution is brushed over its surface. 
Rubber-tissue may be employed very satisfactorily as a 
substitute for this protective. 

Before applying the protective to the wound, it is dipped 
into a solution of bichloride of mercury or carbolic acid. 

Mackintosh. 

This consists of cotton-cloth, with a thin layer of India- 
rubber spread on one side. It is employed in antiseptic 
dressings as the layer placed outside of the gauze, and 
should be applied with the rubber surface toward the 
wound, to prevent the entrance of air and to allow the 
serum from the wound to permeate the gauze and not 
soak directly through the dressings. 

The mackintosh cloth is not at the present time as much 
employed as formerly, unless the moist method of dressing 
is adopted. 



GA UZE-DRESSINGS. 139 



Rubber-dam. 

This is a thin, pure rubber-tissue, and as it has no cloth 
surface like mackintosh, it is cleaned and sterilized with 
greater facility. It is used in applying the moist method 
of dressing to cover the gauze- dressings, and is attached 
to the drainage-tube in abdominal wounds to shut off the 
opening of the tube from the abdominal wound. Before 
being used it should be washed with soap and water, 
rinsed, and then placed in a bichloride or carbolic solu- 
tion for a time sufficient to sterilize it. 

Rubber-tissue. 

This consists of a very thin sheet of India-rubber with 
glazed surfaces, which can be obtained from the rubber- 
manufacturers ; it is employed for the same purposes as 
the mackintosh, is much less expensive, and, as previously 
stated, may be used instead of protective for covering the 
wound. 

Parchment-paper. 

This consists of a very tough paper which can be 
soaked in a watery solution of corrosive sublimate or 
carbolic acid without becoming so much softened as to 
tear upon handling. It is prepared by the manufacturers 
of surgical dressings, and is employed for the same pur- 
poses as mackintosh. 

Gauze-dressings. 

The most convenient and cheapest material for wound- 
dressing is a sheer material known in the trade as cheese- 
or tobacco-cloth. By reason of having a very open mesh 
it absorbs well either the materials with which it is pre- 
pared or the discharges from the wound to which it is 
applied as a dressing. It can be readily obtained any- 
where, is inexpensive, and is soft and pliable, so that it is 
a comfortable form of dressing to the patient. The gauze 



140 MINOR SURGERY. 

is impregnated with different materials to render it anti- 
septic, and its preparation is a matter of little difficulty. 

Preparation of Gauze-dressing. 

Bichloride of Mercury or Corrosive Sublimate 

Gauze. 

In preparing bichloride or corrosive sublimate gauze, 
thirty yards of cheese-cloth are placed in a wash-kettle, 
and covered with water, to which are added two pounds of 
washing soda or a pint of lye, which should be boiled for 
an hour; the soda or lye is added to remove any oily 
matters which the cheese-cloth contains, and thus make 
it more absorbent. The gauze is next removed from the 
kettle, washed in clear water, and passed through a clothes- 
wringer. It should then be immersed in a 1 : 1000 bi- 
chloride of mercury solution for twenty-four hours. It 
is then dried and cut into pieces several yards in length, 
and packed in closely covered glass jars or tin boxes to 
be kept until used. Or it may be preserved as moist 
gauze by packing it in air-tight jars. If gauze has been 
prepared for some time, it is well to soak it for a short 
time in a 1 : 1000 bichloride of mercury solution before 
using it. 

In using the sublimate gauze on delicate skins there will 
sometimes result a dermatitis which is known as mercurial 
eczema ; this is particularly apt to occur if the gauze is 
moistened or covered with rubber-tissue or mackintosh. 
If this condition develops, the parts covered by the gauze 
should be rubbed over with boric acid ointment or vase- 
line before it is reapplied, or another variety of dressing 
may have to be substituted, such as the iodoform or car- 
bolized gauze. 

IODOFORM-GAUZE. 

lodoform-gauze may be prepared by sprinkling cheese- 
cloth, which has been boiled in soda solution, with pow- 



CARBOLIZED GAUZE. 141 

dered iodoform and rubbing it well into its meshes ; it 
should then be dried and packed in glass jars for use. 

It may also be prepared by rubbing an emulsion of 
iodoform, made by adding 3 drachms of iodoform to 6 
ounces of castile soap-suds, into 18 ounces of moist gauze; 
this should be dried and packed in glass jars for use. 

Double Cyanide of Mercury ajstd Zinc Gauze. 

The preparation of this gauze is much more difficult 
than that of the other varieties of gauze, requiring the 
following : 

Potass, cyanide 130 grains. 

Mercuric cyanide 251.7 " 

Zinc sulphate 268.9 M 

Hematoxylin 1.3 " 

Sal ammonia (gas, NH 3 , 1 per cent.) .... 6 minims. 
Gauze (previously boiled and dried) .... 10 ounces. 

Bichloride of mercury solution 7.6 pints. 

Distilled water q. s. 

In charging gauze with this substance, 100 grains of the 
salt are dissolved in 4 pints of a 1 : 4000 bichloride solu- 
tion, which will give from 2 to 3 per cent, of the cyanide 
to the dry gauze. The gauze should be freshly prepared 
and used moist, or, if allowed to become dry, it should be 
moistened again with a weak bichloride solution before 
being used. The advantages claimed for this gauze are 
that it is not irritating to the skin, and as the antiseptic is 
not soluble it is not washed out by the discharges from 
the wound. Prof. J. William White, who has used it 
extensively in his practice, considers that it possesses de- 
cided advantages over the bichloride gauze. 

Carbolized Gauze. 

The carbolized gauze which is used in the University 
Hospital is prepared in the following manner : Cheese- 
cloth, which has been previously boiled and dried, is 
soaked for a few hours in the following solution : 

Resin 1 pound. 

Alcohol 5 pints. 

Castor oil .24 ounces. 

Carbolic acid 12 " 

7* 



142 MINOR SURGERY. 

The gauze is next removed from this solution and passed 
through a clothes-wringer, and is then cut in pieces four 
to six yards in length, which are folded and packed in 
air-tight tin boxes for use. 

Pyoktanin, Salicylated, Borated Gauze. 

Many other varieties of gauze, such as pyoktanin-gauze, 
salicylated gauze, and borated gauze, etc., are prepared, but 
as they are expensive and are not so satisfactory as the one 
which has just been mentioned, they are not much em- 
ployed. 

Sawdust-dressing. 

Sawdust is impregnated with a 1 : 1000 bichloride of 
mercury solution for twenty-four hours, and then spread 
out to dry ; after it has become sufficiently dry it is en- 
closed in bags made of cheese-cloth of various sizes. This 
will be found to be a satisfactory substitute for the ordi- 
nary gauze. In using this dressing the wound should be 
covered with a piece of protective or a few layers of gauze, 
and the bags are then packed over this and held in place 
by a bandage. 

Moss-dressing. 

Different species of sphagnum or moss, on account of 
their cheapness, elasticity, and great absorbing power, 
have been found a very satisfactory material with which 
to make dressing-bags. 

Clean moss is soaked for twenty-four hours in a 1 : 1000 
bichloride of mercury solution and then dried ; cheese-cloth 
bags are filled with this material and may be used dry or 
may be moistened with 1 : 3000 bichloride solution before 
being applied in the dressing of wounds. They are much 
employed in the hospitals of Germany, and have largely 
superseded the gauze-dressings. 



ANTISEPTIC BAN DA GES. 1 43 

Improvised Aseptic or Antiseptic Dressings. 

In cases of emergency, when the ordinary gauze-dress- 
ings cannot be obtained, it is well to remember that old 
muslin or linen, or mosquito-netting, which can usually 
be obtained, will serve for a temporary dressing if prop- 
erly sterilized, until a more elaborate dressing can be 
applied. Old sheets, either of muslin or linen, should be 
torn into pieces half a yard square and thrown into boiling 
water; after remaining for fifteen minutes in this they 
should be removed, and can be used as moist sterilized 
dressings, or soaked for a few minutes in a 1 : 1000 or 
1 : 2000 bichloride solution, or a 5 percent, carbolic solu- 
tion, and applied to the wound, a number of layers of 
this material being applied and held in position by a ban- 
dage. This dressing will keep the wound aseptic until a 
more elaborate dressing is obtained. 

Antiseptic Bandages. 

These bandages are prepared by tearing or cutting 
bichloride or carbolized gauze into strips two or three 
inches in width and five yards in length, and forming the 
strips into rollers and packing them in air-tight vessels. 

The bandages may also be prepared from boiled dry 
gauze in the same manner, and are kept in air-tight boxes 
or jars until required for use, when they are soaked for a 
few minutes in a 1 : 1000 bichloride or 5 per cent, car- 
bolic solution. 

They may also be prepared from crinoline, the same 
material which is used for the plaster-of-Paris bandage ; as 
this material is quite stiff, the bandage should be soaked 
in a bichloride or carbolic solution before being applied, 
and as the material contains a certain amount of starchy 
matter, it becomes firm as it dries, and makes a very secure 
dressing. For this reason it is often applied over the 
antiseptic bandage. 



144 



MINOR SURGERY, 



BlCHLOKIDE-COTTON. 

This material, which is an important part of most anti- 
septic dressings, is prepared by soaking absorbent cotton 
in a 1 : 1000 bichloride of mercury solution for twenty- 
four hours, and then allowing it to dry. When dry, it is 
packed in jars or air-tight boxes. Its great absorbing 
power and its elasticity make it, when properly prepared, 
a most valuable dressing ; it is generally employed to cover 
the gauze-dressing, a number of layers being applied. 

Fig. 101 . 




Sterilizing-oven. 



Borated, carbolized, and salicylated cotton, prepared in 
the same manner, are also frequently employed for a 
similar purpose. 



METHOD B Y SIMPLE BR YING. 1 45 



Moist Sterilized Dressings. 

These may be prepared by steaming the gauze-dressings 
in a steam sterilizer, or by boiling them in covered vessels. 

Dry Sterilized Dressings. 

These dressings are prepared by sterilizing ordinary 
gauze with steam. Gauze cut into proper lengths is placed 
in wire cases and exposed to superheated steam in an oven 
for a few hours, and is then dried in another oven, removed, 
and placed in air-tight jars or boxes. The apparatus re- 
quired for the perfect sterilization of dressings is expensive, 
and is not likely to be employed by practitioners, but is 
used in hospitals where a large number of dressings are 
constantly required. A convenient form of sterilizing 
oven is shown in Fig. 101. Unless the sterilization is 
perfect, these dressings should not be employed ; the same 
method is employed in the sterilization of instruments. 



Methods and Dressings Employed in the Treatment of 
Wounds to Secure Asepsis. 

To prevent infection of wounds the various chemical 
sterilizers and dressings are employed in different ways, 
and the principal types of dressings are as follows : 

Method by Simple Drying. 

This method is employed in small and not very deep 
wounds. The edges having beeu brought together by 
sutures the surface of the wound is dusted with powdered 
iodoform, the serum and blood forming with this, as it 
dries, a scab, which protects the wound from infection from 
without, and repair takes place promptly under this scab. 
Iodoform -collodion may be employed instead of powdered 
iodoform in this method of dressing. 



146 MINOR SURGERY. 

Method by Drying and Chemical Sterilization. 

The object of this method of dressing is to provide a 
means of sterilizing the blood or serum which escapes from 
the wound, and at the same time to insure the sterilization 
of the air coming in contact with the discharges of the 
wound. 

It is employed in large or deep wounds, where there is 
always more or less escape of blood or serum, and is ac- 
complished by applying a number of layers of sublimate 
or iodoform-gauze and sublimated cotton over the wound. 
Evaporation not being interfered with, the whole dressing 
becomes hardened, and the wound is surrounded by a large 
antiseptic crust made up of the dressing and serum or 
blood. 

This method of dressing is the one most generally em- 
ployed at the present time. 

Moist Dressings. 

In this method of dressing, the wound is covered by 
layers of moist gauze, which are kept moist and evapora- 
tion prevented by applying over them some impervious 
material, such as mackintosh or rubber- tissue. 

Modified Moist Dressing. 

In using this method, the wound itself is covered by a 
piece of protective or rubber-tissue ; over this is placed 
the sublimated or iodoform-gauze dressing and some layers 
of bichloride cotton. In this way the wound itself is 
kept in a moist condition favoring particularly the organ- 
ization of blood- clots; the external dressings become 
dry as the discharges which have escaped into them 
evaporate, forming an antiseptic crust or covering over 
the wound. 



DISINFECTION OF THE HANDS. 147 

Preparation for Aseptic Operation. 

Disinfection of the Hands. 

The hands and forearms of the surgeon and of his assist- 
ants should be well washed in hot water with soap for a 
few minutes, and a nail-brush should be used to cleanse 
the region of the finger-nails ; rings with irregular surfaces 
which might retain filth should be removed. After the 
hands and forearms have been thoroughly cleansed, they 
should be immersed in a 1 : 1000 bichloride solution for a 
short time. 

Or the hands and forearms, having been washed with 
soap and water, are dipped in absolute alcohol for one 
minute, and immersed in a warm 1 : 1000 bichloride solu- 
tion and scrubbed with a nail-brush for two or three 
minutes. 

A very satisfactory method of disinfecting the hands 
and forearms consists in first scrubbing them with soap 
and water, then washing them in a solution of perman- 
ganate of potassium prepared by adding an excess of the 
salt to distilled water until they are of a dark-brown color. 
They should next be washed in a saturated solution of 
oxalic acid until completely decolorized, and the oxalic 
acid should finally be removed by washing them in warm 
sterilized water. 

The same precautions should be taken with the hands 
and forearms of the nurses w T ho handle the instruments and 
dressings. If in any manner the hands of the surgeon or 
of his assistants come in contact, during the operation, 
with any objects which have not been disinfected, such as 
the clothing of the patient, the operating-table, etc., it is a 
matter of the first importance that they should be thor- 
oughly rewashed and disinfected before being again brought 
in contact with the wound. 



148 MINOR SURGERY. 

Preparation of Surgeon and Assistants. 

It is desirable that the surgeon and his assistants should 
wear some form of apron or operating-gown, both for the 
protection of the patient and the preservation of their own 
clothing. The operating-gown should be made of muslin 
or linen ; a variety of linen known as butcher's linen is 
very serviceable for this purpose ; it should fit closely 
about the neck and should extend to the ankles, and 
should have sleeves extending at least to the elbows ; it is 
well, for additional protection, to wear under this a rubber 
apron extending from the neck to the feet. The head 
may also be covered with a closely fitting linen skull-cap. 
An improvised apron may be prepared from a clean sheet 
folded so as to be one and a half yards in width and about 
six feet in length, by turning in about ten inches of one 
end of the sheet over the upper part of the chest, and 
placing a strip of bandage in this fold and securing it 
around the neck, and by tying a strip of bandage over the 
sheet at the waist. 

The nurses assisting at the operation should also wear 
aprons and gowns made of wash-goods. 

Sterilizing of Instruments. 

The instruments should be carefully scrubbed with warm 
w r ater and soap, care being taken to see that all joints and 
roughened surfaces are freed from any dry matter which 
may adhere to them ; after being thoroughly cleansed in 
this manner, they should be placed in a metal or porcelain 
tray and covered by a 5 per cent, carbolic solution for 
fifteen minutes before being used. 

The instruments which are now constructed with metal 
handles may be sterilized by placing them in boiling water, 
or by boiling them for ten minutes in a 1 per cent, solu- 
tion of carbonate of soda ; where instruments are employed 
which have wooden handles this method of sterilization 



PREPARATION OF PATIENT FOR OPERATION. J 49 

cannot be employed, and here it will be found necessary to 
resort to the first method of sterilization. 

Instruments which fall upon the floor or come in contact 
with the clothing of the surgeon or the patient during the 
operation, should be washed and placed in the carbolic 
solution, or should be boiled before being again brought in 
contact with the wound. 



Preparation of the Patient for Operation. 

The patient having been prepared for the operation by 
whatever constitutional treatment the surgeon considers 
necessary, the region of the proposed wound is first rubbed 
over with cotton saturated with spirits of turpentine, and 
next is thoroughly washed with soap and water ; if hairs 
are present in the region, they should be shaved off; after 
a careful washing with soap and water, the skin is carefully 
washed with a 1 : 1000 bichloride or 5 per cent, carbolic 
solution, and is then covered with a towel wrung out in a 
1 : 2000 bichloride solution until the surgeon is ready to 
begin the operation. 

This cleansing of the region of the proposed wound in 
hospital practice is generally made a few hours before the 
operation, but in private practice it has often to be done 
just before the operation is undertaken ; if carefully done, 
however, the results will be in no wise less satisfactory. In 
operations upon the face, neck, or chest it is well to apply a 
handkerchief bandage of gauze to cover the hairy scalp. 
In private practice the operation may have to be per- 
formed while the patient is in his bed, or, if an ordinary 
kitchen-table is at hand, it will be found more convenient 
to place him upon this. The table should be prepared by 
placing upon it a folded quilt or blanket, and over this a 
sheet of rubber-cloth, upon which should be laid a clean, 
folded linen or muslin sheet. The surgeon should carry 
with him a sheet of rubber-cloth, three by four feet, which 
he will find most useful in preparing the table for the 
operation, or in protecting the bed of the patient if he is 



150 



MINOR SURGERY. 



not placed upon the table ; a rubber cloth of this size takes 
up little space if carefully folded, and can be easily packed 
in the instrument -bag. 

Details of an Operation in which the Anti- 
septic Method is Employed. 

The patient being anaesthetized and placed upon the 
table, the clothing is so arranged as to expose freely the 
part to be operated upon ; the clothing or the skin sur- 
rounding this region is next covered with towels wet with 
a 1 : 1000 bichloride solution. If any considerable surface 
of the patient's body is covered by these towels, to avoid 
chilling the surface and adding to the shock which natur- 

Fig.102. 




Irrigating-apparatus. (Esmarch.) 



ally follows the operation, they should be wrung out in a 
hot bichloride or carbolic solution, and should be replaced 
as they become cold by hot towels prepared in the same 
manner. The patient being ready for operation, the sur- 
geon should assign the assistants and nurses their duties, 



EMPLOYMENT OF ANTISEPTIC METHOD, 151 

and having again immersed their hands and forearms in 
the bichloride solution the operation is begun. 

During the operation the wound is irrigated frequently 
with a 1 : 2000 or 1 : 3000 bichloride solution, w T hich may 
be allowed to run over the wound, or be applied by means 
of a syringe or irrigating-apparatus (Fig. 93), and the 
hands of the surgeon and assistants should also be washed 
in this solution at not too long intervals. In prolonged 
operations, or in those in which a large wound is made, I 
think it is especially important that the irrigating solutions 
should be used as warm as can be comfortably borne by 
the hands of the surgeon; warm solutions, it has been 
shown by recent investigations, possess a greater germicidal 
power than those of the same strength when used cold, and 
they also possess the advantage of preventing the chilling of 
the patient, and thus diminish the shock of the operation. 

Hemorrhage during the operation is controlled by 
the use of haemostatic forceps, which are applied to the 
bleeding vessels, or the vessels may be ligatured as they are 
divided. After the operation has been completed, and all 
hemorrhage has been controlled, the wound is thoroughly 
irrigated with a 1 : 2000 or 1 : 3000 bichloride solution. 

The next step is to provide for drainage ; this may be 
disregarded in small or superficial wounds, but in a wound 
of any considerable size or depth it is safer to provide free 
drainage. This is accomplished by the use of perforated 
rubber drainage-tubes, or a number of strands of catgut or 
horsehair, or by decalcified bone or glass drainage-tubes. 

The rubber tube in deep wounds will be found most 
comfortable to the patient and satisfactory as regards 
drainage ; it may be laid in the wound, the ends being 
allowed to extend from the extremities of the wound, or it 
may be so introduced that one end of the tube rests in the 
deepest part of the wound and the other extremity is 
brought out of the wound at its most dependent portion ; 
in large or irregularly shaped wounds a number of tubes 
may be required to secure free drainage. The ends of the 
drainage-tubes are transfixed with safety-pins which have 
been sterilized and allowed to remain in a 5 per cent. 



152 MINOR SURGERY. 

carbolic solution until required, and the ends of the tube 
should next be cut off close to the pins so as to be as nearly 
as possible flush with the skin. 

The wound is next closed by the introduction of sutures, 
which may be of silkworm-gut, chromicized catgut, silk, 
or silver wire ; the needles and sutures should be soaked 
in a 5 per cent, carbolic solution for 30 minutes before 
being used. The wound being closed, a final irrigation of 
its deepest parts should be made, by injecting a stream of 
bichloride solution, 1 : 2000 or 1 : 3000, into the end of 
the drainage-tube ; if through-and-through drainage has 
been employed, one end of the tube should be closed and 
the solution should be injected into the wound through 
the other end of the tube by means of a syringe or irri- 
gating-tube, until the wound is slightly distended with the 
solution, which allows the latter to find its way to all parts 
of the cavity of the wound. The external surface of the 
wound and the skin for some distance surrounding it 
should next be washed with a 1 : 2000 bichloride solution, 
and a piece of protective, a little longer and wider than 
the wound, is next dipped in a bichloride or carbolic solu- 
tion and placed over it. The use of this strip of protective 
over the wound is only important if it is desired to keep the 
wound moist, in order to obtain organization of the blood- 
clot, otherwise it need not be employed. Over this is laid 
the deep dressing, which consists of a pad of bichloride 
gauze from eight to sixteen layers in thickness, and large 
enough to overlap the wound two or three inches in all 
directions. This should be dipped in a 1 : 2000 bichloride 
solution, and wrung out as dry as possible before being 
applied. The superficial gauze-dressing is next applied, 
and consists of sixteen layers of gauze, which should be 
large enough to extend from three to six inches beyond 
the wound in all directions ; this gauze is applied dry. 
Over the superficial gauze-dressing there is next applied 
a number of layers of bichloride cotton, so arranged 
as to extend a little beyond the margin of the superficial 
gauze-dressing. These dressings are now secured in 
position by the application of a gauze-bandage, which is 



EMPLOYMENT OF ASEPTIC METHOD. 153 

prevented from slipping by the introduction of a few 
safety-pins. 

Iodoform, carbolized, or any other variety of medicated 
gauze, may be used in the place of the bichloride gauze in 
this method of dressing. The dressings should be volu- 
minous ; it is a mistake to apply scanty dressings. 

The dressing being completed, the patient is moved 
from the operating-table to his bed, and care should be 
exercised to see that the dressings do not become soiled 
if the patient vomits upon coming up from the anes- 
thetic. 

In this method of dressing no mackintosh or rubber- 
tissue is employed, outside of the superficial gauze-dress- 
ing ; the discharges from the wound are disseminated 
through the dressing and become dry by evaporation, and 
the dressing forms an antiseptic scab which covers and 
surrounds the wound. 



Details of Operation in which the Aseptic 
Method is Employed. 

The patient having been prepared for operation and 
placed upon the table, the clothing is arranged so as to expose 
freely the part to be operated upon, which is washed with 
sterilized water, and the surrounding parts are protected 
by sterilized towels. The surgeon and assistants wash 
their hands in sterilized water and the operation is begun ; 
hemorrhage is controlled during the operation by haemo- 
static forceps, and the wound is kept free from blood by 
mopping it with sterilized sponges or pledgets of sterilized 
gauze. When the operation is completed, the vessels are 
tied and the haemostatic forceps are removed. The wound 
is next dried with gauze-pledgets, or, if for any reason 
the surgeon wishes to irrigate the wound, this may be 
done with warm sterilized water or warm sterilized salt- 
solution. The wound may next be closed by the intro- 
duction of deep and superficial sutures without the intro- 
duction of any material for drainage. If, however, the 



154 MINOR SURGERY. 

wound be a deep one and the surgeon considers drainage 
advisable, a sterilized rubber drainage-tube may be intro- 
duced before the sutures are applied. The wound is next 
covered by a number of layers of dry sterilized gauze 
and by some layers of sterilized cotton, and the dressings 
are held in place by a sterilized gauze-bandage. 



Moist Method of Dressing. 

If, for any reason, it is desired to adopt the moist 
method of dressing, a piece of mackintosh or rubber- tissue 
larger than the superficial gauze-dressing is placed over it, 
and over this are placed a few layers of bichloride-cotton, 
care being taken to see that the layers of cotton overlap 
the mackintosh or rubber-tissue by a few inches; the 
application of an antiseptic gauze-bandage then completes 
the dressing. On the removal of this dressing the gauze 
will be generally found to be soaked with the discharges 
from the wound, and in a moist condition. The disad- 
vantage of this variety of dressing is that there is apt to 
be more irritation of the skin set up by the bichloride- 
gauze when kept moist than when applied in the manner 
of a dry dressing. 

KE APPLICATION OF DRESSINGS. 

The re-dressing of a wound which remains aseptic need 
not be made for some days ; if the temperature remains 
normal or a little above this point, and the patient exhibits 
no unfavorable constitutional symptoms, and the dressing 
is comfortable to the patient, it need not be disturbed for 
a week or ten days; at the expiration of this time it is well 
to examine the wound and to remove the drainage-tube if 
a drainage-tube has been used, and to remove a portion or 
all of the sutures if the superficial parts of the wound are 
firmly healed. 

In re-dressing an aseptic wound at the end of a week 
or ten days, to prevent any possible infection, as much 



REAPPLICATION OF DRESSINGS. 155 

care should be exercised as in the original dressing of the 
wound. The patient's clothes should be removed so as 
freely to expose the dressing, and a rubber cloth should be 
placed under the patient so as to protect the bed, and the 
clothing and skin in the region of the wound should be 
protected by towels wrung out in a 1 : 1000 bichloride 
solution. The surgeon should wash his hands and im- 
merse them in a 1 : 1000 bichloride solution before re- 
moving the dressings. The bandage retaining the dressing 
should be divided with bandage-scissors and the gauze 
should be removed layer by layer, and when the deep 
dressing is removed care should be taken to see that the 
drainage-tubes are not pulled upon if they are adherent to 
the dressing ; the protective should next be removed, and 
the surface of the wound should be irrigated with a 1 : 2000 
bichloride solution; the drainage-tubes should next be in- 
spected to see that they are free, and a stream of bichloride 
solution may be passed through them by means of a 
syringe. If the wound is found aseptic, the drainage-tube 
may be removed, and the wound should next be irrigated 
through its track by a stream of bichloride solution, or the 
irrigation of the drainage-tubes or of the sinuses left by 
their removal may be omitted. If the wound is healed, 
the sutures may be removed at this dressing ; but if the 
wound has been an extensive or deep one, it may be well 
to remove only a portion of the sutures ; if animal sutures 
have been employed, they need not be removed. The 
surface of the wound is next washed with a 1 : 2000 
bichloride solution and a piece of protective is placed over 
the line of incision. The deep and superficial dressings 
are applied as previously described and covered with layers 
of bichloride-cotton, and the whole dressing is secured by 
the application of an antiseptic bandage. If the wound 
remains aseptic, the dressings need not be changed for a 
week or ten days, and at this time the wound will usu- 
ally be found healed, so that further dressings are not 
required. 

In the re-dressing of a wound in which the aseptic 
method was employed, the use of germicidal solutions is 



156 MINOR SURGERY. 

, omitted, and the wound is re-dressed with sterilized gauze 
and cotton. 

If, however, the wound is not running the typical 
course of an aseptic wound, constitutional symptoms will 
be developed, as evidenced by a rise in the temperature 
and pulse-rate and other constitutional disturbances. In 
this event the wound should be re-dressed as soon as pos- 
sible, and if the cause of the disturbance can be found, it 
should be removed ; for instance, hemorrhage may have 
taken place into the wound, and the blood not being able 
to escape through the drainage-tubes may have caused so 
much distention of the wound that the vitality of the skin 
covering the wound is threatened, or the sutures may be 
found to be causing irritation, or suppuration may be 
found to be present. 

If, on exposure of the wound, it is found that it is dis- 
tended with blood-clots, and blood is escaping from the 
wound, the sutures should be removed, the clots should be 
turned out, and the bleeding vessel or vessels should be 
sought for and ligatured, and the wound, after a thorough 
irrigation with 1 : 2000 bichloride solution, should be 
drained and closed with sutures, and dressed as previously 
described. 

If, however, on exposure of the site of the operation, 
and upon the removal of a portion or all of the sutures, 
the wound is found distended with a blood-clot, and no 
evidence of hemorrhage at the time exists, or of suppura- 
tion in the wound, the clot may be allowed to remain in 
place, and the wound should be re-dressed as in the original 
dressing, trusting to the organization of the blood-clot if 
it has remained aseptic. If the patient's condition im- 
proves after the dressing, and the temperature and pulse- 
rate become normal, it is an indication that the wound is 
still aseptic, and it need not be re-dressed for some days. 

If, on the other hand, examination of the wound shows 
that the drainage is insufficient, or that the drainage-tubes 
are occluded by blood-clots, these should be removed by 
washing out the tubes with a 1 : 2000 bichloride solution 
by means of a syringe, and introducing additional drain- 



DRESSING OF SEPTIC WOUNDS. 157 

age-tubes, if it is deemed necessary ; the wound should 
then be re-dressed. 

When it is found on examination of the wound that 
suppuration is present, the surgeon may adopt one of two 
methods of treatment : he may thoroughly wash out the 
wound through the drainage-tubes with a 1 : 2000 bichlo- 
ride solution, and after thorough irrigation of the wound 
re-dress it, and, if the patient's constitutional symptoms 
improve, he may be assured that the wound has been ren- 
dered aseptic, and is running an aseptic course. 

If he does uot feel that this method of treatment is 
sufficient, he may open the wound and wash it thoroughly 
with a 1 : 2000 bichloride solution, and next apply to its 
surface a 15- volume solution of the peroxide of hydrogen, 
which may be diluted with water one-third or one-half, or 
a 30-grain solution of chloride of zinc may be used ; and 
after this application a final irrigation with the 1 : 2000 
bichloride solution shall be made, and it should then be 
drained, closed, and dressed, as previously described. 

If the treatment instituted to render the wound aseptic 
has been successful, the patient's constitutional condition 
will improve, and it will heal as an aseptic wound. 

Dressing of Septic Wounds. 

It often happens that patients suffering from wounds 
which have been improperly treated, or have had no treat- 
ment, come under the care of the surgeon ; such wounds 
are already infected, and to render them aseptic, if possi- 
ble, should be the first duty of the surgeon. The most 
important point in the treatment of infected wounds is to 
provide free drainage, and some surgeons depend upon 
this alone and do not attempt to destroy micro-organisms 
which are in the wound by the use of mechanical or germi- 
cidal agents. I think it wiser, however, to treat infected 
wounds in the following manner : The skin surrounding 
the wound should be carefully washed with spirits of tur- 
pentine, and then with soap and water, and finally with a 
1 : 2000 bichloride solution. The wound itself should be 



158 MINOR SURGERY. 

next exposed as fully as possible, and any foreign bodies 
which are found in it, or dirt, should be removed with 
forceps and a stream of water ; it should next be thoroughly 
irrigated with a 1 : 2000 bichloride solution, and then 
should be drained, closed, and dressed as an operation 
wound. 

If suppuration is already present, after cleansing the 
region surrounding the wound, it should be washed with 
peroxide of hydrogen and then irrigated with a 1 : 2000 
bichloride solution. If gangrenous tissues are present in 
the wound, they should be removed w 7 ith the scissors and 
curette, and, if it is found impossible to remove all infected 
tissue in this manner, the affected parts should be touched 
with a 30-grain solution of chloride of zinc applied by 
means of a swab, and the wound should be finally irri- 
gated with a 1 : 2000 bichloride solution. The wound 
should then be wiped dry with gauze and dusted with 
iodoform. 

The introduction of drainage-tubes and sutures will 
depend upon the character of the wound. Sutures cannot 
often be used with advantage if much retraction of the 
skin has occurred, and a drainage-tube is not required if 
the wound is left open. The wound should next be loosely 
packed with strips of iodoform gauze and covered with a 
few layers of iodoform gauze, and the deep gauze dressing, 
wrung out in a 1 : 2000 bichloride solution, is applied 
over this, and the superficial gauze dressing and bichloride 
cotton are next applied and secured by a bandage. 

Infected wounds which are treated in this manner will 
often be rendered aseptic, and in their subsequent course 
will be perfectly satisfactory, both to the patient and to 
the surgeon. 

Materials Used in Surgical Dressings— Continued. 

Lint. 

This material is employed in surgical dressings, and is 
of two varieties : the domestic lint, which consists of pieces 



OAKUM. 159 

of old linen or muslin which have been thoroughly washed 
or boiled and then dried, or the surgical lint which is 
manufactured by machinery, and resembles Canton flannel 
in appearance ; the latter is the best material, as it has a 
greater absorbing capacity. 

Lint is used as a material on which unctuous prepara- 
tions are spread in the dressing of wounds, and is also 
employed as a material for saturating with the various 
solutions which are used in wet dressings, such as lead- 
water and laudanum, or dilute alcohol ; the lint, after 
being saturated with these solutions, is covered with rub- 
ber tissue or oiled silk when applied, to prevent too rapid 
evaporation of the solution. It is also one of the best 
materials from which to construct compresses employed 
in the treatment of fractures, to control hemorrhage, or to 
make pressure for any purpose. 

Paper-lint, made from old rags or wood pulp, has great 
absorbing power for fluids, and may be used as a substi- 
tute for surgical lint in the application of wet dressings to 
surfaces when the skin is unbroken. 

Oakum. 

This material, made from old tarred rope, was formerly 
much employed in the dressing of wounds before the intro- 
duction of the antiseptic method of wound-treatment ; it 
was supposed to possess some antiseptic properties due to 
the tar with which it was impregnated. From its elas- 
ticity it is found to be an excellent material for padding 
splints or other surgical appliances. It is also employed 
in the form of pads to place under patients to relieve por- 
tions of the body from pressure, or to absorb discharges 
which soak through the dressings. A mass of oakum 
which has been well teased out and wrapped in a towel 
forms an excellent pillow on which to support a stump. 
The oakum seton is highly recommended by Dr. Sayre as 
a means of making a direct application of ointments to 
sinuses of bone ; the oakum is loosely twisted into a cord 
and covered with any ointment desired and is passed 



160 MINOR SURGERY. 

through the sinuses in the bone ; the position of the seton 
is changed from time to time, fresh ointment being applied 
before it is drawn through ; resin cerate is a favorite 
application to these sinuses made in this manner. 

Cotton. 

Cotton is now employed in surgical dressings principally 
as a material to pad splints or to relieve salient parts of 
the skeleton from pressure in the application of splints or 
bandages; for instance, in the application of the plaster- 
of- Paris bandage, the bony prominences are generally 
covered by small masses of cotton ; it possesses but little 
absorbent power unless used in the form of absorbent cot- 
ton, and is not much employed in surgical dressings except 
for the purposes mentioned above. 

Absorbent Cotton. 

This material is prepared from ordinary cotton, which 
is boiled with a strong alkali to remove the oily matter 
which it contains. When so prepared it absorbs liquids 
freely, and by reason of its great absorbing capacity it is 
largely employed in surgical dressings. A small mass of 
absorbent cotton wrapped upon the end of a probe or stick 
is now generally employed to make applications to wounds, 
and has taken the place of the sponge or brush which was 
formerly employed for this purpose. On account of its 
cheapness, after one application it can be thrown away 
and a new piece can be used, and thus the danger of car- 
rying infection from one wound to another by the appli- 
cator is abolished. It is largely employed in gyneco- 
logical practice for making applications to the female 
genital organs. 

It may be impregnated with various antiseptic sub- 
stances, such as the bichloride of mercury, carbolic acid, 
boric acid, and salicylic acid, and when thus treated forms 
the bichloride, carbolized, borated, and salicylated cotton so 
much employed in antiseptic dressings. 



RUBBER TISSUE. 161 



Jute. 



This substance is made from the fibre of the Corchorus 
capsularis, which, on account of the character of its fibre, 
possesses both elasticity and absorbing qualities ; it has 
been employed for much the same purposes as oakum and 
cotton, such as the padding of splints, etc., and is also used 
as an external absorbing dressing. 

Wood-wool. 

AVood-wool made from wood-pulp, such as is employed 
in the manufacture of paper, is also furnished in the shape 
of lint, sponges, and pads, and may be used for the same 
purposes as the ordinary surgical lint. 

Oiled Silk or Muslin. 

These materials are employed as an external covering 
for moist dressings to prevent rapid evaporation from the 
dressings ; they form excellent materials for this purpose, 
but as they are quite expensive their use is limited. 

Waxed or Paraffin Paper. 

This dressing is prepared by passing sheets of tissue- 
paper through melted wax or paraffin, and then allowing 
them to dry for a few minutes. Paper thus treated forms 
an excellent and cheap substitute for oiled silk or muslin, 
and may be employed for the same purpose for which the 
latter materials are used. 

Rubber TrssuE. 

This material, which is prepared by rubber manufac- 
turers, consists of rubber run out into very thin sheets. 
It has a glazed surface, is very pliable and at the same 
time strong, forming, therefore, a cheap and satisfactory 
substitute for oiled silk, and is employed for the same 
purposes. In the moist method of antiseptic dressing it 



162 MINOR SURGERY. 

may be used in place of the mackintosh, and indeed I 
prefer it to the latter in this method of dressing. 

Parchment Paper. 

This paper is prepared so as to render it water-proof ; 
it is employed in surgical dressings for the same purposes 
as oiled silk and rubber tissue. 

Compresses. 

Compresses are prepared by folding pieces of lint, muslin, 
linen, or flannel upon themselves, so as to form firm masses 
of variable sizes ; oakum or cotton may also be used to 
form compresses. Compresses are employed to make 
pressure over localized portions of the body, as in the 
treatment of fractures, or to make pressure upon vessels 
for the control of hemorrhage. 

Tampon. 

A tampon is a form of compress which is employed in 
cavities to make pressure, to control hemorrhage, or to 
apply various medicines to the surface of the cavity. 
Tampons used to control hemorrhage are generally made 
of strips of bichloride or iodoform gauze or of pledgets of 
bichloride cotton. In applying these, the strips of cotton 
are packed into the cavity, and when the cavity is full a 
compress is applied superficially and held in place by a 
bandage. The application of a tampon to the vagina is a 
favorite method of controlling uterine hemorrhage. 

A glycerin tampon, made by pouring half an ounce of 
glycerin on a piece of cotton or wool, and then turning up 
the ends and securing them by a string, one end of which 
is allowed to remain long enough to hang from the vagina, 
to facilitate its removal ; it is a favorite application to the 
os uteri. 

Tent. 

This consists of a small portion of lint, oakum, or 
muslin rolled up into a conical shape, which is employed 



RETRACTORS. 



163 



to keep wounds open and to facilitate discharges. This 
dressing is not much employed at the present time, its 
use being largely superseded by the drainage tube. 



Retractors. 

Retractors are made by taking a piece of muslin four 
inches wide and twelve to eighteen inches in length and 



Fig. 103. 



Fig 104. 




Two-tailed retractor. 



Three-tailed retractor. 



splitting it as far as the centre, thus making a hvo-tailed 
retractor. (Fig. 103.) A three-tailed retractor is made in 
the same way, except that the muslin is slit twice instead 
of once. (Fig. 104.) Retractors are used to retract the soft 
parts in amputation, to prevent their injury by the saw in 
the division of the bones. When one bone is sawed a two- 



164 MINOR SURGERY. 

tailed retractor is used, and when two bones are sawed a 
three tailed retractor is employed. 

Plasters. 

The varieties of plaster which are most commonly em- 
ployed in surgical dressings are adhesive or resin plaster y 
isinglass plaster and rubber adhesive plaster. 

Resin Plaster. — This plaster, which is machine-spread, 
is one of the most widely employed plasters in surgical 
dressings ; the spread surface is covered with a layer of 
tissue paper, which should be removed before it is used ; it 
is cut into strips of the required width and length, and the 
strips should be cut lengthwise from the roll of plaster, 
as the cloth upon which it is spread stretches more trans- 
versely than in a longitudinal direction. When heated 
and applied to the surface it holds firmly; it is prepared 
for application by applying the unspread side to a vessel 
containing hot water, or it may be passed rapidly through 
the flame of an alcohol lamp. 

This is the variety of plaster which is generally used in 
making the extension-apparatus for the treatment of frac- 
tures, for strapping the chest in fractures of the ribs and 
sternum, for strapping the pelvis in cases of fractures of 
the pelvic bones, or for strapping the breast, the testicle, 
ulcers, or joints. 

Swan's-down Plaster. — This plaster is much the same as 
resin plaster, but is spread upon a heavier material, and is 
an excellent plaster to use for an extension-apparatus, 
where it is to be worn for a long time. 

Rubber Adhesive Plaster. — This plaster is made by 
spreading a preparation of India-rubber on muslin, and 
has the advantage over the ordinary resiu plaster that it 
adheres without the application of heat. It is employed 
for the same purpose as resin plaster, but when applied 
continuously to the skin it is apt to produce a certain 
amount of irritation, and for this reason when it is to be 
continuously applied for some time, as in the case of an 



PL AS TEES. 165 

extension-apparatus, it is not so comfortable a dressing as 
that made from resin plaster. 

Isinglass Plaster. — This plaster is made by spreading a 
solution of isinglass upon silk or muslin, and it has been 
found a most useful dressing in the treatment of superficial 
wounds. It is made to adhere to the surface by moisten- 
ing it, and when used in the treatment of wounds it should 
be moistened with an antiseptic solution ; it is in this way 
rendered aseptic, and may be used with safety in connec- 
tion with other antiseptic dressings. The best variety of 
this plaster is spread on muslin, and when properly ap- 
plied adheres as firmly and possesses as much strength as 
the ordinary resin plaster. 

Before using any of these plasters upon parts which 
contain hairs, the latter should be removed by shaving, 
otherwise traction upon them, if the plaster be used for 
the purpose of extension, will cause the patient discomfort, 
and unnecessary pain will also be inflicted at the time of 
its removal. 

Soap Plaster. — Soap plaster for surgical purposes is 
prepared by spreading emplastrum saponis upon kid or 
chamois. It is not employed for the same purposes as the 
resin or rubber plaster, as it has little adhesive power, and 
is used simply to give support to parts or to protect salient 
portions of the skeleton from pressure. It is found to be 
a most useful dressing when applied over the sacrum in 
cases of threatened bedsores, and may be applied for the 
same purpose to other parts of the body where pressure- 
sores are apt to occur. 

In the treatment of sprains of joints a well-moulded 
soap-plaster splint secured by a bandage will often be 
found a most efficient dressing, and in the treatment of 
fractures the comfort of the patient is often materially 
increased by applying small pieces of soap plaster over 
the bony prominences, upon which the splints, even when 
well padded, are apt to make an undue amount of pressure. 

Strapping, or applying pressure to parts by means of 
strips of plaster firmly applied, is a procedure often em- 
ployed in surgical practice. 

8* 



166 



MINOR SURGERY. 



Stkapping the Testicle. 

In strapping the testicle strips of resin plaster are usu- 
ally employed ; a dozen or more strips one half an inch 
wide and twelve inches in length will be required. 

The scrotum, should be first washed and shaved, and the 
surgeon next draws the skin over the affected organ tense 
by passing the thumb and finger around the scrotum at 
its upper portion, making circular constriction ; a strip of 
plaster which has been heated is passed in a circular man- 
ner around the skin of the scrotum above the organ, and 
is tightly drawn and secured ; this isolates the part and 
prevents the other strips from slipping. Strips are now 
applied in a longitudinal direction, the first strip being 
fastened to the circular strip and carried over the most 



Fig. 105. 



4fy 





Strapping the testicle. (Smith.) 

prominent part of the testicle, and is then carried back to 
the circular strip and fastened. A number of these strips 
are applied in an imbricated manner until the skin is 
covered (Fig. 105), and the dressing is completed by pass- 
ing transverse strips around the testicle from its lowest 
portion to the circular strip ; care should be taken to see 
that no portion of the skin is left uncovered. 

Strapping the testicle is employed with advantage in 
the subacute stage of orchitis or epididymitis, as the 
swelling of the testicle diminishes the strips become loose, 
and the part will require re-strapping. It will also be 
found a useful means of applying pressure to the scrotum 
after the injection-treatment of hydrocele. 



STRAPPING OF THE CHEST 



167 



Strapping the Breast. 



To strap the breast, strips of resin plaster two inches 
wide and long enough to pass from the opposite shoulder 
under the breast to the point of starting are required. In 
applying the strips the end of the strip is placed on the 
spine of the scapula of the side opposite the diseased breast 
and is carried forward over the shoulder and obliquely 
downward under the breast and axilla, and then over the 
back to the point of starting; the first strip being applied 
in this manner, the next one is applied in the same direc- 
tion overlapping about one- 
third of the previous strip 
(Fig. 106). These oblique 
strips are applied in an im- 
bricated manner until a suf- 
ficient number have been 
used to cover in the breast, 
or the oblique strips may 
be alternated with circular 
strips pa-sing from the ster- 
num over the breast to the 
spine. A sufficient number 
of strips are used to cover 
the breast and to make firm compression upon it. Strap- 
ping of the breast in this manner will be found a satis- 
factory method of treatment in chronic inflammatory con- 
ditions of the breast, w T here it is of advantage to support 
the breast and make compression at the same time ; it has 
the advantage over the use of a bandage to support and 
compress the breast, that it does not interfere with the chest- 
motions upon the opposite side of the body. 




Strapping the breast. (Smith.) 



Strapping of the Chest. 



To strap one-half of the chest, strips of resin plaster two 
and a half inches wide, and long enough to extend from 
the spine to the median line of the sternum, are required — 




168 MINOR SURGERY. 

eighteen to twenty inches in length. The first strip is 
heated and one extremity is placed upon the spine opposite 
the lower portion of the chest ; it is then carried over the 
chest and its other extremity is fixed upon the skin in the 
median line of the sternum. Strips are next applied from 
below upward in the same manner, each strip overlapping 
one-third of the preceding one, 
FlG - 107 - until the axillary fold is reached 

(Fig. 107) ; a second layer of strips 
may be applied over the first, if 
additional fixation is desired, or 
a few oblique strips may be em- 
ployed. 

Adhesive straps applied in this 
manner very materially limit the 
motion of the chest-wall upon the 
affected side, and are frequently 
strapping the chest. empl oy ed in the treatment of frac- 

tures and dislocations of the ribs, 
in contusions of the chest, and in cases of plastic pleurisy 
when the. motions of the chest walls are extremely painful 
to the patient. 

Strapping of Ulcers. 

To strap ulcers of the leg, strips of resin plaster one and 
a half inches wide, and long enough to extend two thirds 
around the limb, are required. The ulcer should be thor- 
oughly cleansed, and the skin surrounding it should be 
well dried ; the first strip, being heated, is applied trans- 
versely to the long axis of the leg about two inches below 
the ulcer, and is carried two-thirds around the limb ; an- 
other strip is applied to a corresponding point of the skin 
above this one, so that it overlaps one-third of the first 
applied strip, and it is carried two-thirds of the way 
around the limb. Additional strips are thus applied until 
the ulcer is covered in, and the strips are carried several 
inches above the ulcer (Fig. 108). Care should be taken 
to see that the strips are so applied as not to meet or 



STRAPPING OF ULCERS. 169 

cover the entire circumference of the limb, as by so doing 
injurious circular compression may result. Chronic ulcers 
upon other portions of the body may be strapped in the 
same manner. 

Fig. 108, 




Strapping of ulcer of leg. 

Strapping of leg ulcers is usually reinforced by the 
applications of a firmly applied spiral reversed or spica 
bandage of the lower extremity. 

Strapping of ulcers of the leg applied in the manner 
described will be found a most satisfactory method of 
treating chronic ulcers in this location in patients who 
have to work during the course of treatment; the strips 



170 MINOR SURGERY. 

need only be removed at intervals of a week, and, if well 
applied, the dressing is generally a comfortable one to the 
patient. 

Strapping of Joints. 

Strips of resin plaster two inches in width and long 
enough to extend two-thirds around the joint are required. 
The first strip is applied a few inches below the joint, and 
strips are then applied over this, each strip covering in 
two-thirds of the preceding one until the joint is covered 
in and the dressing extends a few inches above the joint. 

The ankle-joint is strapped by taking strips of resin 
plaster one inch in width ; the first strip is placed over 
the heel, and its ends are brought forward until they meet 
over the dorsum of the foot ; a second strip encircles the 
foot and secures the ends of the first strip. These strips 
are alternately applied, each strip covering one-half of the 
previous one until the foot and ankle are covered. 

Strapping of joints will be found a satisfactory dressing 
in the treatment of sprains of joints in their acute or 
chronic state. 

Strapping of a Carbuncle. 

To strap a carbuncle strips of resin plaster one to one 
and a half inches in width are required ; these strips are 
applied at the margin of the swelling and are laid on con- 
centrically until all except the central portion is covered. 
If a number of openings exist, the strips are so placed as 
not to cover these. Strapping applied in this manner in 
the treatment of carbuncle is often a comfortable dressing 
for the patient, and at the same time the concentric pressure 
favors the extrusion of the slough. 



Poultices. 

This form of dressing was formerly much employed in 
the treatment of inflammatory conditions and injuries as a 



POULTICES. 171 

means of applying heat and moisture to the part at the 
same time, and although the use of poultices is now very 
much restricted since the introduction of the antiseptic 
method of wound-treatment, yet I think there are still 
conditions in which their employment is both useful and 
judicious. 

They are often employed with advantage in inflammatory 
affections of the chest and of the abdominal organs, and in 
inflammatory affections of the joints and of bone, com- 
bined with rest, their action is most often satisfactory ; in 
cases of gangrene their employment hastens the separation 
of the sloughs. 

They constitute a form of dressing which is conducive 
to the comfort of the patient in cases of deep suppura- 
tion by their relaxing effect upon the tissues, and their 
previous use does not prevent the surgeon from using all 
antiseptic precautions in the opening and drainage of these 
abscesses and the employment of antiseptic dressings in 
their subsequent treatment. 

Flaxseed Poultice. 

This poultice is prepared by adding first a little cold 
water to ground flaxseed and then adding boiling water, 
and stirring it in until the resulting mixture is of the con- 
sistency of thick mush. A piece of muslin is next taken 
which is a little larger than the intended poultice, and 
this is laid upon the surface of a table and the poultice- 
mass is spread evenly upon it with a spatula or knife 
from one-quarter to one-half an inch in thickness ; a 
margin of the muslin of one or one and a half inches is 
left, which is turned over after the poultice is spread, and 
serves to prevent it from escaping around the edges when 
applied. The surface of the poultice may be thinly spread 
over with a little olive oil, or may be covered with a layer 
of thin gauze to prevent the mass from adhering to the skin. 

It is now applied to the surface of the skin and is cov- 
ered with a piece of oiled silk, rubber tissue, or waxed 
paper, and held in position by a bandage or a binder. 



172 MINOR SURGERY. 

Bread Poultice. 

This poultice is prepared from stale wheaten bread, the 
crusts being discarded and the crumb only being used ; 
this is moistened with boiling water and allowed to soak 
for a lew minutes, when the excess of water is poured off 
and the mass is spread upon a piece of muslin or linen, as 
before described. 

Starch Poultice. 

This poultice is prepared by mixing starch with cold 
water until a smooth, creamy fluid results; boiling water 
is then added, and it is heated until it becomes clear and 
has about the same consistency as the starch used for 
laundry purposes. When sufficiently cool it is spread 
upon muslin, applied to the part, and covered with oiled 
silk or waxed paper. This variety of poultice is princi- 
pally useful in the treatment of diseases of the skin, espe- 
cially those of the scalp accompanied by the formation of 
scabs or crusts, to facilitate their removal and to afford a 
clean surface for the application of ointments or wet 
dressings. 

Charcoal Poultice. 

In preparing this poultice flaxseed-meal and powdered 
charcoal in equal parts are mixed together, and by adding 
boiling water a poultice-mass is produced, which is spread 
upon muslin, as previously detailed. It is better to use 
animal charcoal in making this poultice, as it possesses 
greater disinfecting power than vegetable charcoal. This 
poultice was formerly used as an application to gangrenous 
parts, as it possesses marked disinfecting properties. 

Fermenting Poultice. 

This poultice may be prepared by adding yeast, two 
tablespoon fuls, to a mixture of flaxseed with hot w^ater, 
making a thin poultice-mass, and allowing it to stand for 
a few hours in a warm place; it rises and becomes light, 
and is then spread upon muslin and applied as required. 



HOT FOMENT A TIONS. 173 

A few ounces of porter or a piece of yeast-cake may be 
used as a substitute for the yeast in preparing this 
poultice ; charcoal may also be added to it to increase its 
disinfectant power. This poultice was formerly and is 
still used as an application to gangrenous parts to hasten 
their separation and to diminish the odor arising from 
the necrosed tissues. 

Oakum Poultice. 

This is prepared by soaking a mass of loosely picked 
oakum in hot water, wringing it out and covering it with 
a layer of cheese-cloth or antiseptic gauze. It is next 
applied to the part and covered with oiled silk or rubber 
tissue, which may be held in place by a bandage. Such 
a dressing will absord a considerable amount of discharge. 

Before application it may be wrung out in a warm 
bichloride solution or carbolic solution, and thus form an 
antiseptic poultice. 

Hot Fomentations. 

Hot fomentations are employed to keep up the vitality 
of parts which have been subjected to injury, as seen in 
severe contusions resulting from railway or machinery 
accidents; also to combat inflammatory action. Flannel 
cloths, several layers in thickness, or surgical lint should 
be soaked in water having a temperature of 120° ; these 
are wrung out, placed over the part, and covered with waxed 
paper or rubber tissue; a second cloth should be placed in 
the hot water, ready to apply as soon as the first-applied 
cloth begins to cool, and so by continuously reapplying 
them the part is kept constantly covered by a hot dressing. 
The use of these hot fomentations may in many cases 
require to be continued for hours before the desired result is 
obtained. Hot compresses applied in this manner are fre- 
quently employed in treating inflammatory conditions of 
the eye, and are also of the greatest service in keeping up 
the vitality of parts which have been subjected to severe 



174 



MINOR SURGERY. 



injury interfering with their blood-supply. I have seen 
contused limbs, which were cold and seemed to be doomed 
to gangrene by reason of diminished blood-supply, have 
their temperature and circulation restored by the patient 
and persistent use of this dressing. After the vitality of 
such a part is restored it should be covered with cotton 
and a flannel bandage and surrounded by hot- water bags 
or hot- water cans. 

Irrigation. 

This may be accomplished by allowing the irrigating 
fluid to come in contact with the wound or inflamed part, 
immediate irrigation, or by allowing the cold or warm 



Fig. 109. 




Apparatus for continuous irrigation. (Esmakch.) 



IRRIGATION. 



175 



fluids to pass through rubber tubes which are in contact 
with or surround the part ; the latter method is known as 
mediate irrigation. 

Immediate Irrigation. 

In employing immediate irrigation in the treatment of 
wounds or in inflammatory conditions, a funnel-shaped 
can with a stop-cock at the bottom, or a bucket, is sus- 
pended over the part at a distance of a few inches (Fig. 
109), or a jar with a skein of thread or lamp-wick ar- 
ranged to act as a siphon may be employed. (Fig. 110.) 

Fig. 110. 




Irrigating-apparatus. (Erichsen. ) 

The can or jar is filled with water, and this is allowed to 
fall drop by drop upon the part to be irrigated, which 
should be placed upon a piece of rubber sheeting so 
arranged as to allow the water to run off into a receptacle 
so as to prevent the wetting of the patient's bed. The 
water employed may be either cold or warm, in accord- 
ance with the indications in special cases. If it is de- 
sired to make use of antiseptic irrigation, the water is 
impregnated with carbolic acid or bichloride of mercury ; 
a 1 : 5000 to 1 : 10,000 bichloride solution, or a 1 : 60 
carbolic acid solution, being frequently employed with 
good results. 



176 



MINOR SURGERY. 



Antiseptic irrigation employed in this manner will be 
found a most useful method of treating lacerated and con- 
tused wounds of the extremities in which the vitality of 
the tissues is much impaired ; and in such cases warm 
water should be preferred to cool water, the temperature 
being from 100° to 110°. 

Under the use of warm irrigation it is surprising to see 
how tissues apparently devitalized regain their vitality ; 
the absence of tension from the non-introduction of sutures 
and firm dressings, and the warmth and moisture kept 
constantly in contact with the wound by this method of 
irrigation, are the important factors in the attainment of 
this favorable result. 

Mediate Irrigation. 

In this method of irrigation cold or warmth is applied 
to the surface by means of cold or warm water passing 
through a rubber tube in contact with the part. A flexible 



Fig. 111. 




Cold coil applied to arm. (Esmarch.) 



COLD-WATER DRESSINGS. 177 

tube of India-rubber half an inch in diameter, with thin 
walls, and sixteen or twenty feet in length, is applied to 
the limb like a spiral bandage, or is applied in a coil to 
the head, breast, or joints, and held in place by a few turns 
of a bandage ; the end of the tube is attached to a reser- 
voir filled with cold or warm water above the level of the 
patient's body, and the water is allowed to flow constantly 
through the tubing and escape into a receptacle arranged 
to receive it. (Fig. 111.) 

Cold-water Dressings. 

These dressings are applied by bringing the cold water 
either directly in contact with the part or by applying it 
by means of a rubber bag or bladder. 

The temperature of the water may vary from cool water 
to that of ice- water. 

These dressings are employed in local inflammatory 
conditions ; a favorite method for the employment of this 
dressing is by means of cold compresses, which are made 
of a few layers of surgical lint, dipped in water of the 
desired temperature and applied to the part ; they are re- 
newed as soon as they become warm. When it is desirable 
to have the compresses very cold, they may be laid upon 
a block of ice or in a basin with broken ice ; to obtain 
the best results from their employment they should be 
renewed at very short intervals. 

A convenient method of applying cold without moisture 
is by the use of the ice-bag. This is either a rubber bag 
or bladder, which is filled with broken ice and applied to 
the part. In using an ice-bag it is better to cover the part 
first with a towel or a few layers of lint or muslin, which 
prevents the surface from becoming wet by absorbing the 
moisture which condenses upon the surface of the bag or 
bladder, and thus renders the dressing more comfortable 
to the patient. The ice-bag is often employed as an ap- 
plication to the head in inflammatory conditions of the 
brain or membranes, and is also used upon the surface of 
the body to control internal hemorrhage. 



178 MINOR SURGERY. 

Counter-irritation. 

Counter-irritants are substances employed to excite ex- 
ternal irritation, and the extent of their action varies 
according to the material used and the duration of their 
application ; superficial redness or complete destruction of 
the vitality of the parts to which they are applied may 
result. 

The use of counter-irritants under favorable circum- 
stances is found to have a decided effect in modifying 
morbid processes, and they are widely employed as local 
revulsants in cases of congestion or inflammation, and in 
cases of collapse for their stimulating effect. 

Rubefacients. 

These agents, by reason of their irritating properties 
when applied to the skin, produce intense redness and 
congestion. 

Hot Water. — When it is desired to make a prompt im- 
pression upon the skin, the application of muslin or flannel 
cloths wrung out in hot water and renewed as rapidly as 
they become cool will soon produce a superficial redness of 
the integument. 

Spirits of Turpentine. — This drug applied to the skin is 
a very active counter-irritant ; it may be rubbed upon the 
surface of the skin until redness results. When used upon 
patients whose skin is very delicate its action may be 
modified by mixing it with equal parts of olive oil before 
applying it; this will be found a useful precaution in 
applying it as a rubefacient to the tender skins of young 
children. 

When redness of the skin has resulted from the appli- 
cation, the skin should be wiped dry by means of a soft 
towel „or absorbent cotton to remove any turpentine from 
the surface, which by its continued contact may cause 
vesication. 

Turpentine is often employed as a rubefacient in the 
form of the turpentine stupe, which is prepared by sprink- 



R UBEFA CI E NTS. 179 

ling spirits of turpentine over flannel cloths which have 
been wrung out in hot water, or by dipping hot flannel in 
warm spirits of turpentine ; prepared in either way the 
stupe should be squeezed as dry as possible to remove the 
excess of turpentine before being applied to the surface of 
the body. A turpentine stupe may cause vesication if 
allowed to remain for too long a time in contact with the 
skin ; its application for from five to ten minutes will 
usually produce the desired effect ; it should be removed 
after this time, and it can be reapplied if desired. 

If the patient complains of severe burning of the skin 
after the use of turpentine, the painful surface should be 
freely smeared with vaseline or lard, which will relieve 
the uncomfortable symptom. 

Chloroform. — A few drops of chloroform applied to the 
surface of the body by means of a piece of lint, muslin, or 
flannel, and covered by oiled silk or rubber tissue, will 
excite a rapid rubefacient effect. 

3fustard. — Ground mustard or mustard flour prepared 
from either Sinapis alba or Sinapis nigra is one of the most 
commonly used substances to produce rubefacient action. 
It is generally employed in the form of the mustard plaster 
or sinapism, which is prepared by mixing equal parts of 
mustard flour with wheat flour or flaxseed meal, and add- 
ing to this enough warm water to make a thick paste ; 
this is spread upon a piece of old muslin, and the surface 
of the paste should be covered with some thin material, 
such as gauze, to prevent the paste from adhering to the 
skin. In making a mustard plaster for application to the 
tender skin of a child, 1 part of mustard flour should be 
mixed with 3 parts of wheat flour or flaxseed meal. 

A mustard plaster or sinapism may be allowed to remain 
in contact with the skin for a period varying from fifteen 
to thirty minutes, the time being governed by the sensa- 
tions of the patient ; if it is allowed to remain longer, it 
may cause vesication, which is to be avoided, as ulcers 
produced by mustard are very painful and extremely slow 
in healing. After removing a sinapism the irritated sur- 
face of the skin should be dressed with a piece of muslin 



180 MINOR SURGERY. 

or lint spread with vaseline, boric acid or oxide of zinc 
ointment. 

To excite a rapid revulsive action the mustard foot-bath 
is often employed ; it is prepared by adding two or three 
tablespoonfuls of mustard flour to a bucket or foot-tub of 
water at a temperature of 100° to 110°; in this the patient 
is allowed to soak his feet for a few minutes. 

Mustard Papers — Charta Sinapis, which can be obtained 
in the shops ready for use, are a convenient means of 
obtaining the rubefacient action of mustard. They are 
dipped in warm water, and as they are generally very 
strong, it is well to place a layer of muslin between the 
surface of the plaster and the skin before applying it to 
the surface. 

Capsicum or Cayenne pepper is" also sometimes employed 
as a rubefacient, but it is generally employed in combina- 
tion with spices, forming the well-known spice plaster ; 
this is prepared by taking equal parts of ground ginger, 
cloves, cinnamon, and allspice, and adding to them one- 
fourth part of Cayenne pepper ; these are thoroughly 
mixed, enclosed in a flannel bag, and evenly distributed ; 
a few stitches should be passed through the bag at differ- 
ent points, to prevent the powder from shifting its posi- 
tion ; before applying it, one side of the bag should be 
wet with warm whiskey or alcohol. Capsine plasters are 
also employed to obtain the rubefacient effect of Cayenne 
pepper. 

Aqua ammonia may also be employed for its rubefacient 
action. A piece of lint saturated with the stronger water 
of ammonia, placed upon the skiri and covered with 
waxed paper, and allowed to remain for one or two minutes, 
will produce a marked rubefacient effect. 

Paquelin's Cautery. — By rapidly stroking the surface 
of the skin with the point or button of Paquelin's cautery 
at a black heat a marked counter-irritant action may be 
produced. 

Nitrate of silver, in a strong solution or in the form of 
the solid stick, may be applied to the surface of the skin 
to produce a counter-irritant effect. Nitrate of silver ap- 



VESICANTS. 181 

plied by drawing the moist stick across the skin of the 
scrotum at a number of points, was formerly a popular 
form of treatment for acute epididymitis. 

Caution should be exercised in applying counter-irri- 
tants to patients w T ho are comatose or under the influence 
of a narcotic, for here the sensations of a patient cannot 
be used as a guide to their removal, and their too long con- 
tinued application when the vitality of the tissues is im- 
paired may result in serious consequences. 



Vesicants. 

Where it is desirable to make a more permanent counter- 
irritant effect than that produced by rubefacients, sub- 
stances are employed which by their action on the skin 
cause an effusion of serum, or of serum and lymph, beneath 
the cuticle, thus giving rise to vesicles or blisters ; they 
are known as vesicants. 

The substance most commonly employed to produce 
vesication is Cantharis, or Spanish fly, and the prepara- 
tion commonly used is the Ceratum cantharidis, which is 
spread upon adhesive plaster, leaving a margin one-half 
an inch in width uncovered, which will adhere to the skin 
and hold the blister in position. The time required for a 
fly blister to produce vesication is from four to six hours; 
it should then be removed and the surface should be cov- 
ered w T ith a flaxseed-meal poultice, or with a warm-w-ater 
dressing. When the blister or vesicle is well developed, 
it may be punctured at its most dependent part to allow 
the serum to escape, and it should be dressed with vaseline 
or boric ointment. If for any reason it is desired to keep 
up continued irritation, after allowing the serum to escape, 
the cuticle should be cut away and the raw surface should 
be dressed with some stimulating material, such as the 
compound resin cerate. 

Cantharidal Collodion may also be employed to produce 
vesication ; it is applied by painting several layers upon 
the skin with a brush over the part on which the blister 

9 



182 MINOR SURGERY. 

is to be produced. It is a convenient preparation to use 
when the patient would disturb the ordinary blister, as in 
the case of a child or an insane patient, or where the 
surface is so irregular that the ordinary blister cannot be 
well applied. The after-treatment of blisters produced 
by canthariclal collodion is similar to that previously 
described. 

In the treatment of chronic inflammation it is often 
better to apply a number of small blisters at intervals than 
one large blister producing an extensive vesication of the 
surface. Caution should be observed in using blisters 
upon the tender skins of children ; if employed, they should 
be allowed to remain in contact with the skin for a short 
time only. They are contraindicated in patients in whom 
the vitality of the tissues is depressed by adynamic dis- 
eases, and in aged persons. 

A complication which sometimes occurs from the use of 
cantharidal preparations as blisters is strangury, which is 
shown by frequent and painful micturition, the urine often 
containing blood. This accident should be treated by the 
use of opium and belladonna by suppository, demulcent 
drinks, and warm sitz-baths, and by leeches to the peri- 
neum if the symptoms are very severe. 

To avoid the development of strangury small blisters 
should be employed, and should not be allowed to remain 
too long in contact with the surface, and cantharidal prepa- 
rations should not be employed in cases where renal or 
vesical irritation has existed or is present. It is said that 
strangury may also be avoided by incorporating opium 
and camphor with the cantharidal cerate. 

Aqua ammonia fortior and chloroform may be employed 
to produce rapid vesication, a few drops being placed upon 
the surface of the body and covered by an inverted watch- 
glass for a few minutes, or lint saturated with aqua am- 
monia or chloroform may be placed upon the skin and 
covered with waxed paper or oiled silk. Either of these 
agents applied in this manner, and allowed to remain in 
contact with the skin for fifteen minutes, will produce 
marked vesication. The blisters resulting from these 



ACUPUNCTURE. 



183 



agents are painful, and they are only to be used where a 
rapid result is desired. 



Acupuncture. 

Counter-irritation is effected by this method by thrust- 
ing steel needles deeply into the subcutaneous tissues. The 
needles employed should be of steel, from two to four inches 
in length, strong, highly polished, and sharp-pointed, and 
should have round metallic heads or be fixed in handles. 
(Fig. 112.) Before being used they should be allowed to 
remain for a few minutes in boiling water or in a car- 
bolized solution to sterilize them thoroughly. In perform- 
ing the operation of acupuncture, local- 
ities containing important organs, large fig. 112. 
bloodvessels, the joints and viscera, 
should be avoided. When introduced 
the needles should be passed through 
the skin with a rotary motion, the skin 
being rendered tense between the thumb 
and fingers, and pushed into the deep- 
seated structures. They are allowed 
to remain in position for a few moments 
and are then withdrawn, the skin being 
supported by the thumb and fingers. 

Acupuncture has been found of ser- 
vice in cases of deep-seated neuralgia, 
obstinate rheumatic affections, and sci- 
atica. 

Issues. 



Q 



Acupuncture 
needles. 



Issues are ulcers made intentionally 
by the application of caustics, the moxa, 
or the knife. They are not often em- 
ployed at the present time, but were formerly a popular 
means of causing long-continued counter-irritation. In 
making an issue, a region was selected where the subcuta- 
neous cellular tissue was abundant, and which was free 
from large bloodvessels and nerves, and not near the 



184 MINOR SURGERY. 

joints. The plan usually adopted was to apply over the 
surface of the skin a piece of adhesive plaster perforated 
in the centre. A small piece of caustic potash or Vienna 
caustic, mixed with water to make it a paste, was placed in 
the hole in the adhesive plaster, and held in position by a 
strip of adhesive plaster. In one or two hours the plaster 
should be removed and the part should be washed with 
dilute acid to prevent further action of the caustic ; a 
poultice of flaxseed should next be applied, to hasten the 
separation of the slough. The ulcer remaining after the 
removal of the slough may be kept from healing by intro- 
ducing into it a small wooden ball known as an issue pea, 
or a glass bead or pebble held in place by a compress and 
adhesive strap. 

The Moxa was formerly used to make an issue ; it con- 
sisted of a small mass of some combustible material, such 
as punk, cotton, or lint, rolled into pyramidal 
fig. 113. shape, which was placed upon the surface 
of the body and ignited so as to produce an 
eschar upon the skin. To facilitate the appli- 
cation of the moxa an instrument called the 
porte-moxa (Fig. 113) is employed. The 
treatment of the eschar resulting from the 
moxa is the same as that resulting from the 
use of caustic potash. 

The knife was also employed to establish an 
issue, a crucial incision being made through 
the skin and cellular tissues into the deep 
tissues ; the objection to the use of the knife 
in forming an issue was the difficulty in pre- 
venting the wound from healing. 
Porte-moxa. The Seton. — A seton is a subcutaneous 
sinus, or an issue with two openings upon the 
surface, which is prevented from healing by the introduc- 
tion of a foreign body. It is established by introducing 
a few strands of silk, a narrow strip of linen, or a rubber 
ligature, by means of a seton-needle (Fig. 114), or by 
means of a sharp-pointed bistoury and an eyed probe. 
The seton-needle should be passed deeply into the super- 



SETON. 



185 



ficial fascia, care being taken to avoid important veins 
and nerves. 

A seton may also be established by pinching up a fold of 
skin and transfixing its base with a narrow, sharp-pointed 



Fig. 114. 




Seton-needle. 



bistoury (Fig. 115), and passing through the wound thus 
made an eyed probe armed with a few strands of silk, a 
strip of muslin, or an elastic ligature ; the probe is then 
removed and the ends loosely tied together. The wound 



Fig. 115. 




Method of forming a seton. 



should be dressed, and at each change of the dressing the 
strip should be removed, or it may be smeared with some 
stimulating ointment, which can thus be brought in con- 
tact with the granulating surface by drawing it through 
the wound. 



186 



MINOR SURGERY. 



Actual Cautery. 



This method of counter-irritation is accomplished by 
bringing in contact with the skin some metallic substance 
brought to a high degree of temperature. This constitutes 
one of the most powerful means of counter-irritation and 
revulsion ; it is rapid in its action, and is not more painful 
than some of the slower methods. The cauteries generally 
employed are made of iron, and are fixed in handles of 
wood or other non-conducting material, and have their 
extremities fashioned in a variety of shapes (Fig. 116). 
The irons are heated by placing their extremities in an 
ordinary fire, or by holding them in the flame of a spirit- 



Fig. 116. 




Cautery irons. 

lamp until they are heated to the desired point, either 
a white or a dull-red heat. They are then applied to the 
surface of the skin at one point, or drawn over the skin 
in lines either parallel to or crossing one another. The 
intense burning which follows the use of the cautery may 
be allayed by placing upon the cautery-marks compresses 
wrung out in ice- water or saturated with equal parts of 
lime-water and sweet oil. 

Where the ordinary cautery irons are not at hand, a 
steel knitting-needle or iron poker heated in the flame of 
a spirit-lamp or in a fire may be employed with equally 
satisfactory results. Where the cautery iron is held in 



PAQUELIN'S THERMO-CAUTERY. 



187 



contact with the surface for some time to make a deep 
burn, the pain of its application may be allayed by placing 
a mixture of salt and cracked ice upon the spot to be 
cauterized for a few minutes immediately before its appli- 
cation. The cautery iron should not be placed over the 
skin covering salient parts of the skeleton or over impor- 
tant organs. 

The actual cautery thus applied, in addition to its use 
in producing counter-irritation and revulsion, is often 
employed to control hemorrhage and to destroy morbid 
growths. 

Paquelin's Thermocautery. 

A very convenient and efficient means of using the 
thermo-cautery is the apparatus of Paquelin, which utilizes 

Fig. 117. 




Paquelin's cautery. 



the property of heated platinum-sponge to become incan- 
descent when exposed to the action of the vapor of benzole 



188 MINOR SURGERY. 

or rhigolene. (Fig. 117.) The cautery is prepared for use 
by attaching the gum tube to the receiver containing ben- 
zole and heating the platinum knife or button, which is 
also attached to the benzole receiver by a rubber tube, in 
the flame of the alcohol lamp for a few moments, and 
then passing the vapor of benzole through the platinum- 
sponge, which is enclosed in the knife or button, by com- 
pressing the rubber bulb. The points may be brought to 
a high degree of heat, or may be brought only to a dull- 
red heat. 

This form of cautery may be employed for the same 
purposes as that previously mentioned ; its great advantage 
consists in the ease with which it can be prepared for use. 
The knives heated to a dull-red heat will be found of 
great service in operating upon vascular tumors, where 
the use of an ordinary knife would be accompanied by 
profuse or even dangerous hemorrhage. Wounds made 
by the actual cautery are aseptic wounds, and when dusted 
with iodoform will generally heal promptly under the 
scab without suppuration. 

Bloodletting. 

This procedure is often resorted to to obtain both the 
local and the general effects following the withdrawal of 
blood from the circulation. Local depletion is accom- 
plished by means of some one of the following pro- 
cedures : scarification, puncturation, cupping and leeching, 
and general depletion is effected by means of venesection 
or by arteriotomy. 

Scarification. 

Scarification is performed by making small and not too 
deep incisions into an inflamed or congested part with a 
sharp-pointed bistoury ; the incisions should be in parallel 
lines and should be made to correspond to the long axis 
of the part, and care should be taken in making them to 



CUPPING. 189 

avoid wounding superficial veins and nerves. Incisions 
thus made relieve tension by allowing blood and serum to 
escape from the engorged capillaries of the infiltrated 
tissue of the part. Warm fomentations applied over the 
incisions will increase and keep up the flow of blood and 
serum. Scarification is employed with advantage in in- 
flammatory conditions of the skin and subcutaneous cellular 
tissue and in acute inflammatory swelling or oedema of the 
mucous membrane ; for instance, of the conjunctiva, and 
in acute inflammation of the tonsils, tongue, and epiglottis 
it is au especially valuable procedure. A modification of 
scarification known as deep incisions is practised in urinary 
infiltration to establish drainage and to relieve the tissues of 
the contained urine and to prevent sloughing ; in threatened 
gangrene and phlegmonous erysipelas the same procedure 
is adopted to relieve tension by permitting of the escape of 
blood and serum, and its employment is often followed 
bv most satisfactorv results. 



PUNCTURATION. 

This procedure consists in making punctures, which 
should not extend deeper than the subcutaneous tissue, 
into inflamed tissues with the point of a sharp-pointed 
bistoury ; it is an operation similar in character to that 
just described, its object being to relieve tension and bring 
about depletion. It is employed in cases similar to those 
in which scarification is indicated, and is resorted to in 
cases of diffuse areolar inflammation or erysipelas. 

Cupping. 

Cupping is a convenient method of employing local 
depletion by inviting the blood from the deeper parts to 
the surface of the skin. Cupping is accomplished by the 
use of icet or dry cups. When the former are used, no 
blood is abstracted and the derivative action only is 
obtained ; when wet cups are employed there is an actual 

9* 



190 



MINOR SURGERY. 



Fig. 118. 



abstraction of blood or local depletion as well as the 
derivative action. 

Dry Cupping. 

Dry cups as ordinarily applied consist of small cup- 
shaped glasses, which have a valve and stop-cock at their 
summit ; these are placed upon the skin and an air-pump 
is attached, and as the air is exhausted in the cup the con- 
gested integument is seen to bulge into the cavity of the 
cup. When the exhaustion is complete the stop-cock is 
turned and the air-pump is removed, the cup being allowed 
to remain in position for a few minutes, and 
is then removed by turning the stop-cock and 
allowing the air again to enter the cup. This 
procedure is repeated until a sufficient number 
of cups have been applied. (Fig. 118.) 

In cases of emergency, when the ordinary 
cupping-glasses and air-pump cannot be ob- 
tained, a very satisfactory substitute may be 
obtained by taking a wineglass and burning 
in it a little roll of paper, or a small piece of 
lint or paper wet with alcohol, and before the 
flame is extinguished rapidly inverting it upon 
the skin, or the air may be exhausted by the 
introduction, for a moment or two, of the flame 
of a spirit-lamp into the cup. Applied in this 
manner cups will draw as well as when the 
more complicated apparatus is used, and when 
they are removed it is only necessary to press 
the finger on the skin close to the edge of 
the cup until air enters it, when it will fall 
off. Although dry cups do not remove blood 
directly, there is often an escape of blood from the capil- 
laries into the skin and cellular tissue, as is evidenced by 
the ecchymosis which frequently remains at the seat of 
the cupmarks for some days. 

Dry cups, as previously stated, are employed for their 
derivative action in cases in which depletion is not indi- 
cated. 



Cupping- 
glass and 
air-pump. 



LEECHING. 



191 



Wet Cupping. 

When the abstraction of blood as well as the derivative 
action is desired wet cups are resorted to, and here it is 
necessary to have a scarificator as well as the cups and 
air-pump. (Fig. 119.) 

Before applying wet cups the skin should be washed 
carefully with a carbolic solution, and the scarificator 
should also be dipped in a carbolic solution. A cup is 
first applied to produce superficial congestion of the skin ; 
this is removed and the scarificator is applied, and the 
skin is cut by. springing the blades. The cups are im- 
mediately applied and exhausted, and they are kept in 
place as long as blood continues to 
flow. When the vacuum is ex- fig. 119. 

hausted and blood ceases to flow, 
they should be removed and emp- 
tied, and can be reapplied if it is 
desirable to remove more blood. A 
sharp-pointed bistoury which has 
been sterilized may be employed to 
make a few incisions into the skin 
instead of the scarificator, and the 
improvised cups may be employed 
if the ordinary cupping-apparatus scarificator. 

cannot be obtained. 

After the removal of wet cups the skin should be 
washed carefully with a bichloride or carbolic solution, 
and an antiseptic dressing should be placed over the 
wounds and held in place by a roller bandage. 




Leeching. 

In the abstraction of blood by leeching two varieties of 
leeches are used — the American leech, which draws about 
a teaspoonful of blood, and the Swedish leech, which draws 
three or four teaspoonfuls. 

Before applying leeches the skin should be carefully 
washed, and the leech should be placed upon the part from 



192 MINOR SURGERY. 

which the blood is to be drawn, and confined to this place 
by inverting a tumbler or glass jar over him ; if he does 
not bite or take hold, a little milk or blood should be 
smeared upon the surface, which will generally secure the 
desired result. As soon as the leech has ceased to draw 
blood he is apt to let go his hold and fall off; if, however, 
it is desired to remove leeches, they may be made to let go 
their hold by sprinkling them with a little salt. After the 
removal of leeches bleeding from the bites maybe encour- 
aged, if desirable, by the application of warm fomenta- 
tions. Leech-bites should be washed with a bichloride or 
carbolic solution, and a compress of bichloride or iodoform 
gauze should be placed over them and secured by a bandage. 

It sometimes happens that free bleeding continues from 
the leech-bite after the removal of the leeches ; in this 
event, if a compress does not control the hemorrhage, the 
bleeding point should be touched with a stick of nitrate of 
silver or with the point of a steel knitting-needle heated 
to a dull-red heat, and if this fails to control the bleeding 
a delicate harelip pin should be passed through the skin 
under the bite and a twisted suture should be thrown 
around this; the wound should then be washed and 
dressed as previously described. 

In applying leeches in or near mucous cavities care 
should be taken to see that they do not escape into the 
cavities and pass out of reach. Leeches should not be 
employed directly over inflamed tissue, but should be ap- 
plied to parts surrounding it ; they should not be allowed 
to take hold directly over a superficial artery, vein, or 
nerve, and should never be applied to a part where there 
is delicate skin and a large amount of loose cellular tis- 
sue, as in the eyelid or scrotum, as unsightly ecchymoses 
will result, which will persist for some time. Leeches 
should not be used a second time. 

Mechanical Leech. 

The mechanical leech is an apparatus which has been 
constructed to take the place of the leech ; it consists of a 



VENESECTION. 



193 



scarificator, cup, and exhausting- syringe or air-pump. 
(Fig. 120.) In using this apparatus, after the scarificator 
has been used the piston of the exhausting- 
instrument should be drawn out slowly, fig. 120. 
which secures a better flow of blood than if 
a sudden vacuum is made. 

The mechanical leech may be employed 
when the natural leech cannot be obtained, 
but possesses no advantage over the latter, 
and is apt to get out of order if not in con- 
stant use. 

Venesection. 



Venesection, as its name implies, consists 
in the division of a vein, and it is the ordi- 
nary operation by which general depletion 
or bleeding is accomplished. Venesection 
at the bend of the elbow is the operation 
which is now usually resorted to for general 
bloodletting ; the vein selected is the median 
cephalic, which is further from the line of 
the brachial artery than the median basilic 
vein. (Fig. 121.) 

To perform venesection the surgeon re- teech. 

quires a bistoury or lancet — the spring lan- 
cet was formerly much used, but it is not employed at 
the present time — several bandages, a small antiseptic 
dressing, and a basin to receive the blood. 

The patient's arm should be carefully cleansed, washed 
over with a bichloride solution, and a few turns of a roller 
bandage should be placed around the middle of the arm, 
being applied tightly enough to obstruct the venous circu- 
lation and make the veins below become prominent, but 
not tight enough to obstruct the arterial circulation. The 
patient at the same time should be instructed to grasp a 
stick or a roller bandage and work his fingers upon it. 
The surgeon should next assure himself that there is no 
abnormal artery beneath the skin, and having selected the 
vein, the median cephalic by preference, he then steadies 



194 MINOR SURGERY. 

the vein with his thumb and passes the point of the bis- 
toury or lancet beneath it and cuts quickly outward, mak- 
ing a free skin opening. The blood usually escapes freely, 
and the amount withdrawn is regulated by the condition 
of the pulse and the appearance of the patient. For this 
reason it is better to have the patient sitting up or semi- 
reclining when venesection is performed, as the surgeon 
can judge better as to the constitutional effects of the loss 
of blood while the patient is in this position. 

When a sufficient quantity of blood has been removed, 
the thumb is placed over the wounded vein and the 
bandage is removed from the arm above. The wound is 
next washed with a bichloride solution, and a compress of 

Fig. 121. 




Venesection. (Heath.) 

antiseptic gauze is applied over the wound and held in 
position by a bandage which should be so applied as to 
envelop the limb from the fingers to the axilla. The 
dressing need not be disturbed for five or six days, at 
which time the wound is usually found to be healed. 

Wounds of the brachial artery have occurred in opening 
the vein at the bend of the elbow ; but if care is taken, this 
accident should not take place. 

Venesection may be practised on the external jugular 
vein when, from excess of fat or in the case of children, the 
veins at the bend of the elbow cannot be easily found. The 
vein is rendered prominent by placing the thumb or a pad 
over the vein at the outer edge of the sterno-cleido-mastoid 
muscle just above the clavicle. The vein is next opened 



TRANSFUSION OF BLOOD. 195 

over this muscle by an incision parallel to its fibres. After 
a sufficient quantity of blood has escaped, the wound is 
washed with an antiseptic solution and closed by a com- 
press of antiseptic gauze held in position by a bandage 
carried around the neck. 

Bleeding from this vein has been advocated in cases of 
apoplexy and cerebral inflammation, but it is questionable 
whether any advantage is gained by opening the external 
jugular vein rather than the vein at the bend of the elbow. 

The internal saphenous vein is also sometimes selected for 
venesection, and here care should be taken not to wound the 
accompanying nerve which lies directly behind the vein. 

Arteriotomy. 

This operation is now scarcely ever performed, but if 
done the vessel generally selected is the anterior branch of 
the temporal artery. The position of the vessel is fixed by 
the finger and thumb, and it is opened by a transverse in- 
cision with a bistoury. After a sufficient quantity of blood 
has escaped the wound is inspected, and if the vessel is not 
completely divided, its division is completed and the ends 
of the vessel should be secured with ligatures, and the 
wound should be washed out with an antiseptic solution. 
A gauze compress should next be applied and held in 
position by a firmly applied bandage. 

Transfusion of Blood. 

This operation may be employed to introduce a certain 
quantity of blood into the circulation of a patient who has 
suffered from profuse hemorrhage. There are two methods 
by which transfusion may be effected : the direct, by which 
the blood is conveyed directly and without exposure to the 
air from the bloodvessel of one person to that of another, 
and the indirect, in which the blood is first drawn from 
one person and is then injected into the veins of another, 
being first deprived of its fibrin before being injected. 



196 MINOR S URGER Y. 

Direct Transfusion of Blood. 

This is best accomplished by using Aveling's apparatus, 
which consists of a rubber tube, about eighteen inches in 
length, with a small bulb in the centre, having metallic 
extremities provided with stop-cocks, and two bevel-pointed 
metallic canulse to be used to connect the tube with the 
bloodvessels. In performing the operation of direct trans- 
fusion the bulb and tube are first placed in a shallow basin 
containing warm normal saline solution (0.7 percent.), and 
the bulb and tube are filled with this solution to displace 
any air which they may contain. The person supplying 
the blood places his arm near the arm of the patient, and 
the operator exposes a prominent vein on the patient's arm 
at the bend of the elbow, opens it, and inserts into it one 
of the canulse filled with saline solution, with the point 
directed toward the body, and at the same time an assistant 
should introduce the other canula into a vein at the bend 
of the elbow of the party who supplies the blood. 

The canulse are held in position by assistants, and the 
tube is quickly connected with them, the stop-cocks being 
closed before it is taken out of the saline solution, to pre- 
vent the entrance of air ; then upon opening the stop-cocks 
a direct communication is established between the circula- 
tion of the patient and that of the person who supplies 
the blood. (Fig. 122.) The introduction of the contents 
of the bulb into the vein of the patient is effected by the 
operator slowly compressing the bulb with one hand, while 
he keeps the tube closed on the side of the donor with the 
finger and thumb of the other hand. By relaxing the 
pressure on the tube on the donor's side of the bulb and 
closing it on the patient's side, blood will flow from the 
donor's vein into the bulb as it slowly expands, and when 
filled the communication with the patient's circulation is 
again made, and the manipulation is repeated until a suffi- 
cient quantity of blood has been introduced as indicated by 
the condition of the patient's pulse. 

The quantity of blood or saline solution introduced can 
be calculated by remembering that at each emptying of 



TRANSFUSION OF BLOOD. 



197 



the bulb two drachms of fluid are introduced into the cir- 
culation. When a sufficient quantity has been introduced 



Fig. 122. 




Apparatus for the direct transfusion of blood. 

the canuke are removed and the wounds are dressed as 
ordinary venesection-wounds. 



Indirect Transfusion of Blood. 

Indirect transfusion of blood is accomplished by with- 
drawing from a vein of the donor by venesection about ten 
ounces of blood, which is received in a clean glass or porce- 
lain vessel, which is placed in water at a temperature of 
110°. The blood thus kept warm is next defibrinated by 
whipping it with a bundle of broom straws or a wire brush, 
and after being filtered through a fine linen cloth or wire 
strainer, it is injected by means of an ordinary syringe 
attached to a canula which has previously been inserted 
into a vein of the patient ; care should be taken that no 
air is introduced with the blood. When a sufficient 
quantity of blood has been introduced, the canula is re- 
moved and the wound is dressed in the usual manner. 



198 



MINOR SURGERY. 



The success of this operation largely depends upon the 
expedition with which it is performed ; to prevent the 
coagulation of the blood not more than two minutes should 
be allowed to intervene between the reception of the blood 
in the syringe and its introduction into the patient's vein. 



Fig. 123. 




Apparatus for the indirect transfusion of blood. 

Various forms of apparatus have been devised for the 
operation of indirect transfusion of blood, and of these one 
of the best is that devised by Dr. J. G. Allen and modified 
by the late Dr. C. T. Hunter. (Fig. 123.) 

Arterial Transfusion. 

This procedure, which consists in injecting defibrinated 
venous blood into an artery, is occasionally practised. An 
artery, usually the radial at the wrist or the. posterior 
tibial behind the inner malleolus, is exposed and secured 
by a ligature ; it is then opened on the distal side of the 
ligature and the point of a canula or the nozzle of a syrinze 
is introduced, directed toward the distal extremity of the 
limb, and blood, which has been previously defibrinated, 
is slowly injected. When a sufficient quantity has been 
introduced the canula is removed, and the division of the 
artery is completed and its extremities are secured by liga- 
tures, and the wound is closed and dressed. 



INTRA VENO US INJECTION OF SALINE SOL UTION 199 

Auto-transfusion. 

This procedure is recommended in cases of excessive 
hemorrhage to support a moribund patient until other 
means of resuscitation can be adopted. It consists in the 
application of rubber bandages or of muslin bandages to 
the extremities for the purpose of forcing the blood toward 
the vascular and nervous centres. 

Intravenous Injection of Saline Solution. 

It has been proved by experiments and by clinical 
experience that human blood is not more efficacious in 
supplying volume to and restoring a rapidly failing circu- 
lation than normal salt solution, and as the latter can be 

Fig. 124. 




Funnel and tube for intravenous injection. 

obtained with much more ease than blood, its use has largely 
superseded the former. The saline solution which is found 
most satisfactory to employ for this purpose is known as 
normal saline solution (0.7 per cent.). It is prepared by 
adding sodii chloride, 5iss, sodii bicarb., grs. xv, to dis- 



200 MINOR SURGERY. 

tilled water, Oij. In emergencies a solution prepared by 
adding a drachm of common salt to a pint of water, which 
has been sterilized by boiling, will be equally satisfactory. 

The solution should be prepared with water which has 
been boiled to sterilize it, and should be of a temperature 
of about 100° when used. 

A vein of the patient, at the elbow, should be exposed 
and should have placed under it, about one-half inch apart, 
two catgut ligatures ; the distal ligature is then tied and 
an opening is made into the vein between the ligatures; a 
canula is next inserted into the opening in the vein, and 
is secured in position by tying the proximal ligature. The 
canula is first filled with the saline solution, and is then 
connected with a funnel by means of a rubber tube (Fig. 
124), which is filled with saline solution to displace the 
air, and upon raising the funnel above the part the solu- 
tion enters the vein ; care should be taken to see that the 
funnel is kept well supplied with solution until a sufficient 
quantity has been introduced. The quantity introduced 
is regulated by the condition of the patient's pulse. 

Saline solution may also be introduced into a vein by 
means of a syringe when the apparatus described cannot 
be obtained, or normal salt solution may be introduced 
into the cellular tissue by means of hypodermic injections, 
or the needle may be introduced into the cellular tissue 
and connected by a piece of rubber tubing with an irri- 
gator containing normal salt solution held above the part, 
and the solution allowed to find its way gradually into the 
subcutaneous cellular tissue. A large quantity of fluid 
may be introduced in this way. 

Intravenous Injection of Milk. 

The intravenous injection of cow's or goat's milk has also 
been employed as a substitute for the transfusion of blood 
in patients who have suffered from excessive hemorrhage 
or from diseases which greatly deteriorate the quality of 
the blood, such as pernicious anaemia, typhoid fever, and 
in carbolic acid poisoning. In making one of these injec- 



ARTIFICIAL RESPIRATION. 201 

tions the milk should be fresh and should be warmed and 
strained through a fine wire or linen strainer. It should 
then be introduced by means of a canula inserted into a vein 
and secured in position by a ligature ; to this canula are at- 
tached the rubber tubing and funnel, such as are employed 
in the intravenous injection of saline solution. The 
funnel and tube are next filled with milk prepared as 
above described, and it is made to enter the vein of the 
patient by turning the stop-cock and raising the funnel 
above the patient' s body. This injection has been em- 
ployed in the class of cases mentioned above with appar- 
ently beneficial results. 

Artificial Respiration. 

This procedure is resorted to in cases of threatened 
death from apnoea consequent upon drowning, profound 
anesthetization or the inhalation of irrespirable gases, or 
when from any cause there is interference with the func- 
tion of breathing. Before resorting to artificial respiration 
care should be taken to see that nothing is present in the 
mouth or air-passages which will obstruct the entrance of 
air into the lungs, such as mucus, foreign bodies or liquids, 
and also that all tight clothing interfering with the free 
expansion of the chest-walls should be removed from the 
chest. 

In cases where the apnoea is due to the presence of a 
foreign body in the larynx or trachea it is evident that 
no efforts at respiration can be successful until the air- 
passages are freed from the occluding body ; and if it can- 
not be removed through the mouth, tracheotomy should be 
performed before artificial respiration is attempted ; the 
tracheal wound should be held open by retractors, which 
in a case of emergency can be made from bent hairpins, or 
by a tracheotomy-tube, if one be at hand. 

When artificial respiration is resorted to the operator 
should persevere with it for some time, even when no 
apparent spontaneous respiratory movements are excited ; 
for resuscitation has been accomplished in seemingly hope- 



202 MINOR SURGERY. 

less cases by patient perseverance with the manipula- 
tions. 

When the first natural respiratory movement is detected 
the operator should not cease making artificial respiration, 
but should continue these movements in such a way as to 
coincide with the spontaneous inspiratory and expiratory 
movements until the breathing has assumed its regular 
character. 

The temperature of the body should also be restored by 
frictions to the surface of the body by the hands or by 
rough towels and hot-water bottles, and warm coverings 
should be applied for the same object. 

Mouth-to-mouih Inflation. 

This method of artificial respiration has been resorted 
to in cases of great emergency, especially in very young 
children. The operator draws the tongue forward, closes 
the nostrils, and applies his mouth directly to the mouth 
of the patient, and by a deep expiratory effort endeavors 
to force air into the chest ; when this is accomplished the 
air can be expelled from the lungs by pressure upon the 
walls of the chest, and the procedure should be repeated 
about sixteen times in a minute. The same object may be 
accomplished by passing a flexible catheter into the trachea 
through the mouth, or by passing an intubation-tube, to 
the upper part of which a rubber tube is attached, into 
the larynx ; this can be passed with the fingers without 
difficulty, and the lungs can then be inflated by the opera- 
tor blowing into the catheter or tube, or by attaching to 
it a pair of bellows. 

Inflation of the lungs through the nostrils has been 
employed by Dr. Richardson, of London, who has devised 
a pocket-bellows for this object. The apparatus consists of 
two elastic bulbs, to which two rubber tubes are attached, 
which terminate in a single tube. In using this bellows 
the terminal tube is introduced into one nostril, the other 
nostril and mouth being closed; air is forced into the 
lungs by compressing one bulb, and withdrawn by com- 
pressing the other bulb. (Fig. 125.) 



ARTIFICIAL RESPIRATION. 203 

This bellows may also be attached to a catheter or in- 
tubation-tube passed into the larynx, which would prevent 
the possibility of air escaping into the oesophagus, a com- 

FlG. 125. 




Richardson's bellows for artificial respiration. 

plication which is liable to occur in mouth-to -mouth infla- 
tion or inflation through the nose. 

Direct Method of Artificial Respiration (Howard's). 

This method of artificial respiration is at the present time 
considered the most efficacious, and is the one adopted by 
the United States Life-saving Service, and although the 
rules given are for the resuscitation of cases of apparent 
drowning, the same procedures may be adopted in cases of 
apnoea arising from other causes. 

The rules laid down by Dr. How r ard are as follows : 

Rule I. — " To expel water from the stomach and lungs, 
strip the patient to the waist, and if the jaws are clenched 
separate them and keep them apart by placing between the 
teeth a cork or a small piece of wood. Place the patient 
face downward, the pit of the stomach being raised above 
the level of the mouth by a large roll of clothing placed 
beneath it. (Fig. 126.) Throw your weight forcibly two 
or three times upon the patient's back over the roll of 
clothing so as to press all fluids in the stomach out of the 
mouth. " 

The first rule applies only to eases of drowning, and in 



204 



MINOR SURGERY. 



using Howard's method in apnoea from other causes it is 
to be omitted. 



Fig. 126. 




First manipulation in Howard's method. 

Rule II — " To perform artificial respiration, quickly 
turn the patient upon his back, placing the roll of clothing 

Fig. 127. 




Direct method of artificial respiration. 



beneath it so as to make the breast-bone the highest point 
of the body. Kneel beside or astride of the patient's hips. 



ARTIFICIAL RESPIRATION. 205 

Grasp the front part of the chest on either side of the pit 
of the stomachy resting the fingers along the spaces between 
the short ribs. Brace your elbows against your sides, and 
steadily grasping and pressing forward and upward throw 
your whole weight upon the chest, gradually increasing 
the pressure while you count one — two — three. Then sud- 
denly let go with a final push which springs you back to 
your first position. (Fig. 127.) Rest erect upon your knees 
while you count one — two ; then make pressure again as 
before, repeating the entire motions at first about four or 
five times a minute, gradually increasing them to about 
ten or twelve times. Use the same regularity as in blowing 
bellows and as seen in the natural breathing which you are 
imitating. If another person is present, let him with one 
hand, by means of a dry piece of linen, hold the tip of the 
tongue out of one corner of the mouth, and with the other 
hand grasp both wrists and pin them to the ground above 
the patient's head." 

This method may be employed in cases of still-birth, or 
in young children, the operator holding the chest of the 
child in his left hand and compressing it with the right 
hand. 

Sylvester's Method of Artificial Respiration. 

In employing this method of artificial respiration the 
patient should be placed on his back upon a firm, flat sur- 
face ; a cushion of clothing is placed under the shoulders, 
and the head should be dropped lower than the body by 
tilting the surface on which he is laid. The mouth being 
cleared of mucus or foreign substances, the tongue is 
drawn forward and secured to the chin by a piece of tape 
tied around it and the lower jaw, or may be pulled out of 
the mouth and held by an assistant. The operator, stand- 
ing at the patient's head, grasps the arms at the elbows 
and carries them first outward and then upward until the 
hands are brought together above the head ; they should 
be kept in this position for two seconds, after which time 
they are brought slowly back to the sides of the thorax 

10 



206 



MINOR SURGERY. 



and pressed against it for two seconds. These movements 
are repeated fifteen times in a minute until the breathing is 
restored, or until it is evident that the case is a hopeless one. 



Fig. 128. 




Sylvester's method— Inspiration. (Esmarch.) 
Fig. 129. 




Sylvester's method— Expiration. (Esmarch.) 



ARTIFICIAL RESPIRATION. 207 



Marshall HalPs Ready Method of Artificial Respiration. 

In this method the mouth should first be freed from 
mucus or foreign bodies, and the patient is turned upon 
his face with one wrist under his forehead, and a roll of 
clothing is placed beneath his chest. By turning the body 
briskly on the side and a little beyond, and then on the 
face, alternately, respiration is imitated. As the body is 
brought in the prone position, compression is to be made 
upon the posterior aspect of the chest. These manipula- 
tions should be made fifteen times in a minute. 

Laborde 1 s Method of Artificial Respiration by Rhythmical 
Traction upon the Tongue. 

Laborde has shown that systematic and rhythmic traction 
upon the tongue is a powerful means of restoring the respi- 
ratory reflex, and consequently the function of respiration. 
The procedure is accomplished as follows : The body of 
the tongue is seized between the thumb and fingers, and 
traction is made upon it, with alternate relaxation fifteen 
or twenty times a minute, imitating the function of respi- 
ration, taking care to draw well on the tongue. When a 
certain amount of resistance is felt it is a sign that the 
respiratory function is being restored. Noisy respiration 
first occurs, termed by Laborde " hoquet inspirateur " (in- 
spiratory hiccough). Tongue forceps or dressing or haem- 
ostatic forceps may be used in place of the fingers to 
grasp the tongue. It is important to persist in the manipu- 
lations for half an hour to an hour, unless the case is abso- 
lutely hopeless. This procedure has been employed with 
success in cases of drowning, toxic asphyxia, chloroform 
asphyxia, and arrest of inspiration from electric shock. 

Forced Respiration. 

By this method of artificial respiration air is for- 
cibly passed into the lungs. This procedure is strongly 



208 MINOR SURGERY. 

advocated by Dr. George E. Fell, who has devised 
an apparatus by which it may be satisfactorily accom- 
plished. Prof. H. C. Wood has also made use of forced 
respiration in the resuscitation of animals with an appa- 
ratus somewhat similar to that devised by Dr. Fell with 
good results, but has never applied it practically in the 
case of the human subject. Wood's apparatus consists of 
a pair of bellows, a few feet of rubber tubing and a face 
mask of rubber, and one or two intubation-tubes; the 
mask or intubation -tube is attached to one end of the rub- 
ber tube and the bellows to the other end of the tube. 
The mask is applied over the mouth, or, if this is not used, 
the intubation-tube is introduced into the larynx, and air 
is forced into the lungs by working the bellows. He also 
advises that in the tubing a double metal tube be intro- 
duced, with the openings so placed that their size can be so 
regulated by turning the outer tube that the operator can 
allow any excess of air thrown by the bellows to escape. 

The apparatus of Fell, which he has used in a number 
of cases with good results, consists of a tracheotomy-tube, 
a tube connected with the air-control valve, which is 
attached to an air-warming apparatus, which in turn is 
connected with a bellows by another tube. By means of 
this apparatus air is forced into the lungs and allowed to 
escape when the lungs have been expanded by the elasticity 
of the lung tissue and the chest walls. 

Forced respiration will prove of value in cases of nar- 
cotic poisoning and other accidents in which death is pro- 
duced by paralysis of the respiratory centres. Dr. Fell 
has reported a number of cases of narcotic poisoning in 
which he has used his apparatus with the most satisfactory 
results. 

Aspiration. 

This procedure is adopted to remove fluid from a closed 
cavity without the admission of air, and the instrument 
which is employed to accomplish this object is known as 
an aspirator. The two forms of aspirator most generally 
employed are those of Dieulafoy and Potain. 



ASPIRATION. 



209 



Potain's aspirator consists of a glass bottle, into the 
stopper of which is introduced a metallic tube, which is 
connected with two rubber tubes, one of which is con 
nected with an exhausting-pump, and the other with a 
delicate canula carrying a fine trocar ; the apparatus is 
provided with stop-cocks to prevent the admission of air. 
(Fig. 130.) In using this aspirator the air is exhausted 
from the bottle by using the air-pump ; the canula enclosing 
the trocar is next pushed through the tissues into the cavity 
containing the fluid to be removed ; the trocar is then re- 



FlG. 130. 




Potain's aspirator. 



moved, and upon opening the stop-cock the fluid is forced 
out of the cavity by atmospheric pressure and passes into 
the bottle or receiver. If the fluid contains masses of 
lymph or clots which block the canula, interrupting the 
flow of fluid, a stylet may be passed through the canula 
to free it from the obstruction. 

To diminish the pain produced in introducing the trocar 
and canula, the skin at the point to be punctured may be 
rendered less sensitive by holding in contact with it for a 
few minutes a piece of ice wrapped in a towel, or a towel 



210 MINOR SURGERY. 

containing broken ice and salt. Care should also be taken 
to see that the trocar and canula are perfectly clean ; to 
accomplish this it should be carefully washed and placed 
in boiling water or a 5 per cent, carbolic solution before 
being used. 

In introducing the trocar and canula the operator should 
be careful to avoid injuring any important veins, arteries, 
or nerves. 

After removiog the canula the small puncture should 
be dressed with a compress of antiseptic or iodoform gauze 
held in place by a bandage or adhesive straps. 

The aspirator is frequently employed in cases of hydro- 
thorax, empyema, and ascites, to evacuate the contents 
of cold abscesses in diseases of the hip and spine, and to 
remove the contents of a distended bladder until a more 
radical operation can be performed. It is also a valuable 
instrument for diagnostic purposes, being frequently used 
to ascertain the character of the contents of deep-seated 
tumors containing fluid. 

The Stomach-tube. 

This consists of a tube about twenty-eight inches in 
length and three-eighths of an inch in diameter, which is 
introduced while the patient is in the sitting posture, the 
head being thrown backward so as to bring the mouth and 
gullet as nearly as possible in the same line. The tube 
being warmed and oiled, the surgeon standing in front ot 
the patient passes it directly back to the pharynx, at the 
same time introducing the index finger of the left hand to 
guide its point over the epiglottis ; it is then passed gently 
downward into the stomach. If any obstruction is met 
with in its passage, it should be withdrawn a little way and 
then pushed gently downward ; all manipulations should 
be made without much force to prevent perforation of the 
wall of the oesophagus. 

The introduction of the stomach-tube may be required 
for the evacuation of poisons from the stomach, or to wash 



THE STOMACH-PUMP. 211 

out the cavity of this viscus. It may also be used to 
introduce liquid nourishment into the stomachs of patients 
who are unable or unwilling to swallow food. In the 
recently introduced method of treating disorders of the 
stomach and intestines by washing them out, lavage, the 
introduction of a stomach-tube is required ; the tube here 
employed is from twenty-four to thirty inches in length 
(Fig. 131), and the fluid is introduced by means of a funnel 
attached to its free extremity, or it may be attached to a 
stomach-pump. In introducing liquid nourishment a 
syringe or funnel is fitted to the exposed end of the tube 
which has been passed into the stomach ; the syringe or 

Fig. 131. 
The stomach-tube. 

funnel having been filled with milk or beef-tea or broth, 
the contents are injected gently or allowed to run into the 
stomach. 

In cases of poisoning, where it is desirable to withdraw 
the contents of the stomach and to wash out the organ, a 
stomach-tube and syringe may be employed ; several 
syringefuls of warm water are first thrown into the 
stomach and then withdrawn by suction, but in such 
cases the use of the stomach-pump will be found more 
satisfactory. 

The Stomach-pump. 

This consists of a brass syringe, the nozzle of which is 
connected with two tubes, one at the end, the other at the 
side. The passage through the nozzle is regulated by a 
valve controlled by a lever. The nozzle of the pump is 
attached to a stomach-tube, and the end of the lateral tube 
is placed in a pan of warm water. By raising the piston 
and opening the valve, water may be drawn from the basin, 
and by closing the valve and depressing the piston it is 



212 



MINOR SURGERY. 



passed through the stomach -tube into the stomach ; when 
a sufficient quantity has been injected in this manner, by 
reversing the action of the valve the fluid is drawn out of 
the stomach and discharged through the lateral tube into 
a basin. This manipulation is continued until the water 
returns clear and the stomach has been completely washed 
out. A less complicated instrument w r ill often serve as 
well as that just described (Fig. 132). 

Fig. 132. 




Stomach-pump. 

(Esophageal Bougie. — This instrument — which may be 
passed through the oesophagus into the stomach for the 
purpose of diagnosis, or for the purpose of dilating stric- 
tures of the oesophagus — is passed in exactly the same 
manner as the stomach-tube, and, as in the case of the 
latter instrument, it should be introduced without the use 
of much force, as perforations of the oesophagus have fol- 
lowed the forcible introduction of such bougies. 

Vaccination. 



This is a minor surgical procedure which every physi- 
cian is called upon to perform. The surface may be pre- 
pared for the reception of the lymph by abrading the 



VACCINATION. 213 

surface of the skin at one or two points with a dull lancet, 
or by making several superficial incisions with a knife, or 
by scratching the surface of the skin with the ivory-point 
charged with lymph, in lines with crossing lines, cross- 
scratch, until a little serum exudes. It is not advisable to 
draw blood, which washes away the lymph, and for this 
reason I prefer the abraded surface made by the dull knife 
or the ivory-point. 

The lymph used may be the humanized or the bovine. 
The humanized lymph may be the viscid fluid taken from 
the vaccine vesicle on the eighth or ninth day, or the dried 
scab w r hich separates when the wound is about healed ; if 
the latter is used, a small portion of it is rubbed up with 
water until it forms a mixture of creamy consistence ; this 
is rubbed into the abraded surface of the punctures. In 
using humanized lymph care should be taken to see that 
it is procured from a healthy subject. 

Bovine lymph or virus, which is now most generally em- 
ployed, is taken from the vaccine vesicles upon the udders 
and teats of heifers ; ivory-points or quills are dipped into 
this lymph and allowed to dry, and in using them they 
are dipped in water for a moment, to moisten the lymph, 
before being applied to the abraded surface. The ivory- 
point is one of the most convenient means of vaccination, 
as the surface may be abraded with it before the lymph is 
applied. 

It has recently been advised that antiseptic precautions 
be exercised in performing vaccination, and although all 
of the details cannot be carried out, I have found that the 
exercise of care as regards cleanliness of the surface has 
been followed by much fewer inflammatory complications 
in vaccination-wounds. In an institution in which I 
vaccinated yearly a large number of cases, since I have 
adopted the following precautions I have had fewer bad 
arms. 

The surface to be abraded, usually the left arm below the 
deltoid, is first washed with soap and water, and then with 
a 1 : 2000 bichloride solution. Two points of this surface, 
an inch apart, are then abraded by using a knife which has 

10* 



214 MINOR SURGERY. 

been washed or dipped in boiling water, or by using the 
ivory-point which has been dipped in water which has 
been boiled and cooled down. When the surface has been 
prepared in the manner described, the moistened virus is 
rubbed upon it and allowed to dry. Vaccination upon 
the leg, which is practised by some physicians to prevent 
the scar from showing, I think is not to be recommended, 
and I never practise it in this situation, as it is more diffi- 
cult to keep this part at rest, and I have seen some very 
severe cases of cellulitis and phlebitis follow leg vaccination. 

Hypodermic Injections. 

The syringe used to make hypodermic injections is pro- 
vided with a perforated needle, which is passed into the 
cellular tissue. (Fig. 133.) Care should be taken to see 

Fig. 133. 




Hypodermic syringe and needles. 



that the instrument and needle are perfectly clean before 
being used; if a metallic syringe is employed, it should 
be rendered aseptic by soaking it for a few minutes in 
boiling water or in a five per cent, carbolic solution. 
Hypodermic injections are generally made into parts in 
which the cellular tissue is abundant, and great care should 
be observed to avoid introducing the needle into a large 
vein or artery, as by neglect of this precaution serious 
symptoms have resulted, from the drug being thrown 



HYPODERMIC INJECTIONS. 215 

rapidly into the circulation instead of being slowly ab- 
sorbed from the subcutaneous cellular tissue ; the injury of 
superficial nerves should also be avoided. Care should 
also be taken to see that the solutions employed are 
sterilized if possible, and freshly made solutions should be 
preferred. 

An unclean syringe or a solution which has not been 
sterilized may give rise to a troublesome abscess at the site 
of the injection. 

To avoid using solutions for hypodermic use which un- 
dergo change from being kept, it will be found convenient 
to use the compressed pellets which are prepared by the 
manufacturing chemists, the alkaloids being compressed 
with a little sulphate of sodium, which increases their 
solubility, the solution being prepared with boiled water 
just before being used. 

Fig. 134. 




Method of giving a hypodermic injection. 

The portions of the body usually selected for hypodermic 
injection are the outer surface of the thighs or arms and 
the anterior surface of the forearm. In making a hypo- 
dermic injection the syringe is charged and the needle is 
fastened to the nozzle of the syringe ; the skin is next 
pinched up and the needle is quickly thrust through this 
into the cellular tissue ; the syringe is then emptied by 
pressing down the piston, and when the cylinder is empty 
the needle is withdrawn ; the small puncture in the skin 
resulting seldom bleeds and usually heals without diffi- 
culty. (Fig. 134.) 

In the treatment of disease by the injection of serum the 



216 



MINOR SURGERY. 



hypodermic method is made use of; in using antitoxin 
injections in diphtheria the dose of the antitoxin is pro- 
portionate to the age and weight of the patient as well as the 
severity and duration of the disease. A child three years 
old should be given 600-1000 units ; an adult, not less 
than 1000 units, and the injection should be repeated in 
twelve to twenty-four hours. Before employing the in- 
iection the skin should be sterilized, and the best variety 
of syringe to employ is one holding about 20 c.c. (Fig. 

Fig. 135. 




H. K. MULFORD CO., PHILADA. 

Syringe for serum-injection. 

135). It is well to have the needle connected with the 
syringe by a short rubber tube, so that the needle will not 
be broken if the patient straggles. The injections are 
usually made below the angle of the scapula or in the 
lumbar region, and the serum is introduced slowly to 
avoid local reaction. 

EXPLORING-NEEDLE. 

This consists of a fine-grooved needle fitted into a handle 
(Fig. 136), which is introduced into tumors or swellings 



Fig. 136. 




Exploring-needle. 

to ascertain the nature of their contents, and its use is often 
of service for purposes of diagnosis. The exploring-trocar 



SKIN-GRAFTING. 217 

(Fig. 137) is employed for the same purpose, or the needle 
of the hypodermic syringe or a fine needle attached to an 
aspirator may be used for a like purpose. When either 
the exploring needle or trocar is employed care should be 
taken to see that it is rendered perfectly aseptic before 

Fig. 137. 



Exploring-trocar. 



being used ; otherwise its employment is not without 
danger, for I have seen the introduction of an exploring- 
needle into an effusion in a joint for diagnostic purposes 
followed by suppuration and destruction of the joint, which 
subsequently necessitated its excision. 



Skin-grafting. 

This is a minor surgical procedure which may be em- 
ployed to hasten cicatrization w T here large granulating 
surfaces are exposed, such as result from extensive opera- 
tions and from burns. 

The operation consists in applying shavings of the epi- 
dermis or of the epidermis and cutis together, to the granu- 
lating surface and holding them in contact with it for a 
few days ; the grafts often seem to disappear, but at the 
end of a few days, if the part is closely inspected, bluish- 
w T hite points will be seen to occupy the positions at which 
the grafts are applied, which become converted into iso- 
lated cicatrices from which the healing process rapidly 
extends. To have a successful result follow the use of 
skin-grafts the surface of the ulcer should be healthy, and 
its surface as well as the surrounding skin should be 
rendered aseptic, and the grafts should be applied at a 
number of points. 

The surface from which the grafts are to be taken should 
also be rendered aseptic, and the skin should be removed by 



218 MINOR SURGERY. 

scissors made for this purpose (Fig. 138), or by raising the 
epidermis with a needle or with forceps and cutting out a 
small portion of it with a sharp scalpel. The graft is 
next applied to the granulating surface with its raw sur- 
face in contact with the granulations ; after a sufficient 
number of grafts have been applied, a piece of sterilized 
protective is laid over them and is held in place by means 
of a few strips of isinglass plaster. An ordinary anti- 
septic or sterilized gauze dressing is next applied, and the 
dressing is not disturbed for a week or ten days, at Avhich 
time, if the grafts have taken, isolated cicatrices at the 
points where the grafts were applied will be found to exist. 

Fig. 138. 




Scissors for skin-grafting. 

Thiersch's Method. — In skin-grafting, according to this 
method, the surface of the ulcer is rendered aseptic, and 
all antiseptics are washed away with sterilized salt solution. 
The surface of the ulcer is next curetted to remove soft 
granulations, and it is then irrigated and covered with pro- 
tective and a compress is applied to control all bleeding. 

Shavings of skin are then removed from a surface — which 
has been rendered aseptic — by means of a razor or section 
knife. Each graft should be as long and broad as possi- 
ble, and when cut it should he floated from the section 
knife by a stream of salt solution and placed upon the pre- 
pared surface of the ulcer and gently pressed into place. 

After a sufficient number of grafts have been applied, 
strips of protective are laid over the surface of the grafts, 
and over these is placed a compress moistened with salt 



BONE-GRAFTING. 219 

solution and covered by protective, and a few layers of 
sterilized cotton are next applied over this, and the dress- 
ing is held in position by a bandage. 

The dressings need not be removed for a week or ten 
days, and a second dressing should be applied in the same 
manner until the grafts have become thoroughly vitalized. 

The skin of the belly or backs of frogs, or the hairless 
skin of young animals may be used in the place of human 
skin. 

Skin-grafting is sometimes accomplished by applying a 
large piece of skin to a raw surface to fill a gap ; the graft 
in such cases includes the whole thickness of the skin, but 
has all of the cellular tissue removed from it, and is secured 
in position by sutures. 



Bone-grafting. 

This procedure is resorted to to replace portions of bone 
which have been separated, to fill up cavities in bone, or 
to restore the continuity of the long bones. The bone to 
be introduced should be rendered thoroughly aseptic and 
should be placed in a sterilized salt solution at a tempera- 
ture of 100°-105° F. ; it may be inserted in one piece or 
broken into fragments and laid over the surface. 

When it is desired to restore the continuity of one of 
the long bones, after the surfaces of the bone have been 
exposed and rendered aseptic, a bone is removed from a 
freshly killed animal, is rendered aseptic, and is fitted into 
the gap or is split into strips and packed into the cavity. 

Bone-grafting may also be very satisfactorily accom- 
plished by means of Sennas decalcified bone plates or chips, 
which will be found useful in filling up the cavities result- 
ing from the operation of trephining or for extensive re- 
movals of bone in the operations for necrosis or caries. 

In such cases, after the cavity has been sterilized, it is 
dusted with iodoform and is then packed with bone chips ; 
iodoform is next dusted over them and a piece of protec- 
tive is placed upon them. A compress of iodoform gauze 



220 MINOR SURGERY. 

and bichloride cotton is next applied, and the dressing is 
held in position by a bandage. 

When bone plates are employed they are cut to fit the 
cavity, and provision should be made for drainage. 

Preparation of Decalcified Bone Chips or Plates. — Take 
the compact tissue of the fresh tibia or femur of an ox, 
remove the periosteum and medullary tissue, and split in 
pieces one-half an inch in width, and place them in a 15 
per cent, watery solution of hydrochloric acid, allowing 
them to remain in this for three weeks, changing the 
solution daily. At the end of this time they should be 
removed, thoroughly washed and cut in thin strips or 
plates. They should then be washed in a weak solution 
of caustic potash, and placed for forty-eight hours in a 
1 : 1000 bichloride solution. 

After this they may be kept in a solution of iodoform 
in ether, or in a 1 : 500 solution of bichloride in alcohol 
until required for use ; before being used they are soaked 
in a 1 : 2000 bichloride solution. 

Muscle-grafting and nerve-grafting are also occasionally 
resorted to to supply deficiencies in muscles or nerves ; 
fresh muscle or nerve tissue being employed to fill up the 
gap. 

Electeolysis. 

Electrolysis, or the chemical decomposition induced by 
electricity, is employed in surgery to destroy morbid prod- 
ucts, tumors, or exudations. For this procedure a galvanic 
or continuous-current battery is required, which is pro- 
vided with electrodes and needles of suitable shapes. In 
applying electrolysis to a tumor, for instance, the needle 
connected with one of the poles of the battery is inserted 
into the tumor and the other rheophore is applied to the 
surface of the body, or two fine needles, carefully insulated 
nearly to their extremities, are connected with both poles 
of the battery by conducting cords ; these are introduced 
into the tumor and a weak current is allowed to pass. The 
strength of the current is gradually increased as the opera- 



GALVANO-CAUTERY. § 221 

tion advances ; the current is passed for fifteen or twenty 
minutes, and the procedure is repeated at intervals of 
several days, until some decided change occurs in the 
tumor. 

Electrolysis has been applied with success in the treat- 
ment of aneurism inaccessible to other operative procedures, 
in malignant growths, in nsevi, goitres, cysts, and hydatids. 
It is at the present time the most satisfactory method of 
removing superfluous hairs from those portions of the body 
in which their presence causes disfigurement. 

Galvano-cautery. 

Galvano-cautery batteries are constructed with plates of 
large size, placed closely together, so that the internal re- 
sistance is reduced and a current is quickly obtained which 
will keep a metallic electrode at a w T hite heat. The ad- 
vantage in the use of this form of cautery is that the elec- 
trode can be introduced into the various cavities of the 
body while cold and quickly heated to the desired tempera- 

Ftg. 139. 




Electrodes for galvano-cautery. 

ture. The electrodes are made of various shapes and sizes, 
according to the object desired (Fig. 139). The galvano- 
cautery is applied for the same purpose as the actual 
cautery, but, as previously stated, its use is more conve- 
nient in the various cavities of the body, its action can 
be more easily localized, and by its use hemorrhage is 
avoided. It is frequently employed to destroy morbid 
growths in the nasal passages, the throat, vagina, or uterus, 
and also may be employed in the treatment of superficial 
external growths; in using it for the removal of growths 



222 MINOR SURGERY. 

from the mucous membrane its application may be ren- 
dered practically painless by previously thoroughly cocain- 
izing the parts. 

Faradization. 

The application of electricity in this form is often em- 
ployed in surgical affections ; in cases of wasting of the 
muscles following fractures or sprains, in some forms of 
club-foot, and in lateral curvature of the spine the judi- 
cious use of the faradic current will often be found to be 
followed by the most satisfactory results. The current is 
applied in such a manner as to bring about contraction of 
the affected or wasted muscles, and thus improve their 
nutrition. 

Franklinization, or Statical Electricity. 

The earliest application of electricity in the treatment 
of disease was made by the use of statical electricity, and 
although it fell into disuse it has recently, with the perfec- 
tion of modern machines, been very widely revived. In 
applying statical electricity the patient may be treated by 
insulation, or the so-called dry electric bath. The second 
method of using statical electricity is by sparks or shocks 
from a Leyden jar which is charged from the prime con- 
ductor of an electrical machine in motion, or by the electric 
brush. McClure states that in the static induced current 
we have means of producing muscular contractions when 
failure results from the strongest faradic currents that can 
be borne by the patient. 

The Cystoscope. 

This is an instrument employed for ocular examination 
of the walls of the bladder, and is one of the most impor- 
tant and useful of the electric-lamp instruments. A cysto- 
scope consists of a beak-sound in which there is a telescopic 
arrangement by which the inner surface of the bladder is 



THE URETHROSCOPE. 



223 



viewed through a small window of rock crystal. The lamp 
is inclosed in the beak of the instrument and throws its 
light through another window, also of crystal, upon any 
part of the bladder wall. For examining the upper part 
of the bladder, a separate instrument with a small reflect- 
ing prism is used. The bladder must contain six or eight 
ounces of clear urine or clear water if a proper view of 
the walls is to be obtained. If the fluid present is turbid, 
the view is very much obscured ; if too little fluid be 
present in the bladder, the the beak of the instrument 



Fig. 140. 




Letter's cystoscope. 

containing the lamp is likely to become buried in the folds 
of mucous membrane and the light will be cut off, and, in 
that case, the mucous membrane may be burned. A certain 
amount of practice is required to use the cystoscope prop- 
erly and to recognize the appearance of the raucous mem- 
brane of the bladder in health and in its varied morbid 
conditions. 

The Urethroscope. 

The urethroscope consists of a straight metal tube pro- 
vided with an obturator of hard rubber which projects 
slightly beyond the end of the tube. This tube is intro- 
duced into the urethra until the bladder is reached, when 
it is slightly withdrawn and the obturator is removed. 



224 



MINOR SURGERY. 



The instrument is then attached to a mirror or an electric 
lamp, by which a strong light is thrown into the tube, and 
as the tube is withdrawn various parts of the urethra are 



Fig. 141. 




The urethroscope. 



exposed to the view of the surgeon. By means of the 
urethroscope a very accurate inspection of all portions of 
the urethra can be obtained. 



The Panelectroscope. 

This instrument, introduced by Leiter, consists of an 
electric lantern with tubes and a mirror. The light from 
a small incandescent lamp is projected by the mirror along 
the tube, which is inserted into the part to be examined. 
Tubes of various sizes are adapted to the instrument. It 
is employed for endoscopy of the urethra, ear, pharynx, 
and stomach. 

Massage. 

Massage consists in a variety of manipulations, such as 
pinching up the integuments and muscles, and rolling them 
between the thumb and fingers, in stroking or rubbing the 
surface with the palm of the hand from the periphery 



PASSIVE MOTION. 225 

toward the centre, to empty the distended veins and lym- 
phatics ; rubbing the parts circularly with the extremities 
of the fingers and thumb or the palm of the hand, or 
kneading of the parts is another method of practising 
massage. Massage may also be practised by tapping the 
surface of the affected part with more or less force with the 
tips of the fingers held in a row, or with the ulnar border 
of the hand or with the palm of the hand. Before apply- 
ing massage to an affected part, if there be a heavy growth 
of hair, it should be carefully shaved off; otherwise the 
manipulation may give the patient pain, and irritation of 
the hair follicles resulting in abscesses will be apt to occur. 
The part should also be rubbed over with olive oil, vase- 
line, or cocoa-butter before and during the manipulations. 
Massage is often employed with advantage in the treat- 
ment of sprains and strains in their subacute and chronic 
stages. It will also be found of great service in the later 
treatment of fractures involving the joints or their vicinity, 
in restoring the motion of the parts as well as in improv- 
ing the nutrition of the muscles which have become wasted 
from disuse. 

Passive Motion. 

This manipulation consists in alternately flexing and 
extending or rotating the limb to imitate the normal joint- 
movement. The motions should be carefully practised, 
and in cases of fracture they should not be undertaken 
until there is quite firm union at the seat of fracture, or if 
for any reason passive motion is made use of before this 
time the fragments should be firmly supported while it is 
being employed. Other forms of massage, such as stroking 
and kneading, may be employed in conjunction with pas- 
sive motion in the treatment of the troublesome stiffness 
of joints resulting from fractures, dislocations, and sprains; 
passive motion applied in this manner will often restore 
the function of a stiff joint more satisfactorily and with 
less pain to the patient than the forcible manipulations of 
the joint which are practised under an anaesthetic. 



226 MINOR SURGERY. 

The Clinical Thermometer. 

For clinical observations two thermometer scales are in 
general use, the Centigrade and Fahrenheit ; the latter is 
the one commonly employed in America and England. 
This scale has a limited range above and below the normal 
bodily temperature, which is 98 J- ° Fahrenheit or 36° 
Centigrade. Thermometers are now made with a convex 
surface, which serves to magnify the column of mercury, 
and thus enables the observer without difficulty to note the 
position of the index. (Fig. 142.) 

Fig. 142. 



110 J 



9 5 100 



Clinical thermometer. 

The temperature of the body may be taken in the mouth, 
axilla, vagina, or rectum ; the two former positions are 
those generally employed. When taken in the axilla care 
should be exercised to see that no clothing is interposed 
between the skin and the instrument, and when the mouth 
is used for thermometric observations the patient should 
be instructed to keep his lips tightly closed and breathe 
through his nose. The thermometer should be kept in 
place for from three to five minutes. 

Surface thermometers are sometimes employed, the in- 
struments for this purpose having bulbs of a discoid shape, 
or are drawn out in the form of a spiral or coil. (Fig. 
143.) In using this form of thermometer to determine 

Fig. 143. 



Surface thermometer. 

the amount of variation of the surface temperature, the 
temperature of corresponding parts of the body on the 
opposite side and the general temperature of the body 
should be taken at the same time. 



RECTAL BOUGIES, 227 



The Rectal Tube. 



The introduction of the rectal tube is best accomplished 
by placing the patient upon his left side, and the surgeon 
should introduce his index finger well oiled into the rectum 
and guide the tube upon this through the anus, and by 
gentle pressure it is gradually passed into the rectum ; if 
a stricture exists in the rectum within reach of the finger, 
the latter should be used to guide the tube through the 
opening in this ; if the tube becomes caught in a transverse 
fold of the mucous membrane, and becomes doubled upon 
itself, it should be withdrawn and a fresh attempt should 
be made to pass it; in passing a rectal tube all manipula- 
tions should be made with extreme gentleness, as it has 
been shown that its passage is not without danger, perfora- 
tions of the intestine having followed its use in some cases. 
In cases of stricture of the rectum high up the operator 
has to depend upon the sense of resistance experienced in 
passing the tube, and in such cases the manipulations 
should be most carefully made. When the rectal tube is 
employed to introduce fluidsin to the large intestine the 
fluids may be introduced by means of a syringe, or by 
pouring them into a funnel attached to the free end of the 
tube, or by attaching the tube to a fountain syringe, thus 
allowing the liquid to pass slowly into the intestine. 

The rectal tube is often employed with good results in 
relieving the intestine of excessive flatus, and in intro- 
ducing water or oil into the intestine in cases of intestinal 
obstruction, and in those cases where the obstruction re- 
sults from intussusception or fecal accumulations its use 
will often prove satisfactory. 



Rectal Bougies. 

These instruments are made of the same material as the 
English flexible catheter, and are of various sizes. They 
should first be oiled, and carefully introduced in the same 
manner as the rectal tube. They are generally employed 



228 MINOR SURGERY. 

in cases of stricture of the rectum, and they should be used 
with great care to avoid perforating the wall of the rec- 
tum. A very satisfactory substitute for a rectal bougie 
is a tallow candle, one end of which is melted or rubbed 
down to a conical shape. 

Enemata. 

These may be administered by means of the ordinary 
syringe, or by means of a gravity or fountain syringe; the 
precautions which should be observed are to introduce the 
nozzle of the syringe gently and in the right direction, as 
perforation of the lower portion of the rectum has taken 
place from the careless and forcible introduction of the 
nozzle of the enema-syringe ; the fluid should also be in- 
jected slowly, as by so doing there is less resistance and 
less tendency for the patient to pass the fluid before the 
desired quantity has been introduced. 

The enema most commonly employed to empty the lower 
bowel is made by adding a tablespoonful of sweet oil and 
two teaspoonfuls of spirits of turpentine to one or two 
pints of warm water in which a little castile soap has been 
dissolved ; warm water and sweet oil are also frequently 
used for the same purpose. 

Glycerin Enema. — One or two teaspoonfuls of glycerin 
injected into the rectum, or a suppository made of gly- 
cerin, will often be found an efficient substitute for the 
larger enemata of water. 

Nutritious Enemata. 

When it is found necessary to resort to feeding by the 
rectum, the substances employed should be injected into 
the rectum by means of a syringe, and care should be 
taken to see that the quantity is not too large, and that it 
is of such a nature as not to cause any irritation of the 
walls of the rectum, or it will not be retained ; two ounces 
in the case of an adult are generally a sufficient quantity 
to inject at one time. 



LOCAL ANESTHESIA. 229 

Peptonized milk or beef juice, or the yolk of an egg 
beaten up with milk, is often employed, and any unirri- 
tating drugs may be mixed with the enema and adminis- 
tered at the same time. 



Ansesthetics. 

The substances which are employed at the present time 
to produce either local or general anaesthesia are ice, co- 
caine, rhigolene, nitrous oxide, chloroform, and ether. 

Local Anesthesia. 

Cold. 

Local anaesthesia may be produced by the application of 
cold, either by a piece of ice or a mixture of ice and salt 
held in contact with the part for one or two minutes, or 
by directing a spray of rhigolene or sulphuric ether upon 
the surface of the part whose sensibility is to be obtunded. 
(Fig. 144.) 

Fig. 144. 



Application of rhigolene spray. 

Chloride of Ethyl is also used to produce local anaesthesia, 
and is conveniently furnished in glass tubes, one end of 
which is drawn out into a fine point and hermetically 
sealed. When used the end of the tube is broken off and 
a fine jet of ethyl is projected upon the surface, the warmth 
of the hand being sufficient to force the fluid from the tube. 

11 



230 MINOR SURGERY. 

This form of local anaesthesia is made use of in minor 
surgical procedures, such as aspiration , the opening of ab- 
scesses, and the removal of superficial tumors. 

Rapid Respiration, 

Rapidly repeated deep inspirations kept up for a few 
minutes will produce insensibility to pain, but sensibility 
to contact is not obliterated. This form of anaesthesia 
may be made use of in slight operations, such as the open- 
ing of an abscess. 

Cocaine. 

Local anaesthesia produced by the employment of an 
aqueous solution of the hydrochlorate of cocaine, in strength 
from 1 to 10 per cent., is often made use of in minor sur- 
gical procedures. Where the mucous membrane is to be 
operated upon or growths removed from it, analgesia is 
produced by brushing the surface over with the solution 
of cocaine, or by applying a compress of absorbent cotton 
saturated with the solution to the part for a few minutes ; 
in mucous cavities the latter method of application will be 
found most convenient. In using a solution of cocaine to 
produce anaesthesia in operations upon the eye a 2 or 4 per 
cent, solution is dropped into the eye, and the application 
is repeated until the analgesia is complete. 

In applying cocaine to the urethra a 1 to 10 per cent, 
solution is injected into the urethra, and is allowed to re- 
main for two or three minutes ; more than one or two 
grains should not be injected at one time, as fatal results 
have followed the injection of larger quantities ; this is 
especially the case in using cocaine in the urethra and 
the rectum, and in these situations great caution should be 
exercised in its use. 

Experience has proved that there is always danger in 
the use of the stronger solutions of cocaine, so that it is 
now considered wise not to use a solution stronger than 1 
or 2 per cent., as the full analgesic effect can be obtained 
by a solution of this strength. 



LOCAL ANESTHESIA. 231 

When it is desired to produce local anaesthesia of the 
skin or deeper tissues the application of the solution of 
cocaine to the surface is not satisfactory, and it should in 
such cases be injected hypodermically into the deeper 
layers of the skin and into the cellular tissue of the parts 
to be operated upon ; to avoid multiple punctures the needle 
is not completely withdrawn from the wound, but its di- 
rection is changed and the solution is thrown into different 
portions of the tissues. It is well in situations where it 
can be accomplished to cut off the circulation from the 
part to be operated upon by placing around it a rubber 
strap or tube, which prevents the rapid absorption of the 
cocaine into the general blood-current. 

Some persons also have an idiosyncrasy for cocaine, and 
children seem more susceptible to its constitutional effects 
than adults. I have seen several instances in children in 
which marked symptoms of cocaine- poisoning resulted from 
the application of a 4 per cent, solution to the nasal mucous 
membrane. 

In minor surgical operations, such as amputations of the 
finger, circumcision, opening of abscesses, and removal of 
superficial tumors, cocaine-anaesthesia may be employed 
with advantage ; but its utility is most marked in opera- 
tions upon the eye and upon the mucous membranes of 
the nose, throat, rectum, vagina, and urethra. Applied 
for a few minutes to the surface of an ulcer which is to 
be cauterized, it will render the operation almost painless 
to the patient. 

Infiltration Ancesthesia. 

It has been shown by Liebreich that the injection of 
simple water into the tissues in such a way as to produce 
an artificial oedema induces a transitory anaesthesia. 

Schleich found that the combination of a minute quan- 
tity of cocaine and morphine with a weak salt solution, 
when injected hypodermically, produced a local anaesthesia 
of longer duration. 

The anaesthesia is produced by the artificial ischaemia, 
by the pressure of the injected fluids upon the nerves, and 



232 MINOR SURGERY. 

by the direct action of the anaesthetic substances on the 
nerves. 

A solution of 1 part of cocaine to 1000 parts of steril- 
ized water may be used, or the following solution may be 
employed : 

Cocaine hydrochlor gr. iss. 

Morphise hydrochlor. gr. y^. 

Sodii chloridi gr. iij. 

Aquae Siijss. 

The injection should be first made into the substance of 
the skin itself, and then into the cellular tissues and deeper 
structures as desired. 



Nitrous Oxide Gas. 

This gas is administered for the purpose of producing 
anaesthesia, and the apparatus best suited for its adminis- 
tration consists of a cylinder of metal in which the gas is 
compressed ; this is attached to a rubber bag which has a 
mouthpiece fastened to it ; this is provided with a double 
valve, which prevents the expired air from passing back 
into the bag. The mouthpiece is adjusted over the mouth, 
and after removing any false teeth, or foreign bodies, from 
the mouth, the patient is instructed to take deep, full 
breaths, and in from one-half to one minute the face be- 
comes congested and dusky, and the breathing becomes 
stertorous, indicating that the patient is fully under the 
influence of the gas. The anaesthesia from nitrous oxide 
cannot be prolonged for more than a few minutes, so that 
it can only be employed in operations which take a short 
time for their performance, such as the extraction of teeth, 
the opening of abscesses, and the reduction of dislocations 
or fractures. In England nitrous oxide is frequently used 
to produce anaesthesia, and when this result is accomplished 
the anaesthesia is kept up by the administration of ether 
by the employment of a special apparatus devised for this 
purpose. Nitrous oxide gas is most commonly employed 
in dental surgery to produce anaesthesia for the removal of 
teeth, but is also occasionally employed in minor surgical 



ETHER. 233 

operations ; but from the fact that the apparatus for its 
administration is a bulky one, its use is not so convenient 
as ether or chloroform, and in this country it is not much 
employed in general surgery. 

Ether. 

Sulphuric ether is one of the most widely employed 
substances in surgery to produce anaesthesia ; it is probably 
the safest of all anaesthetics, except nitrous oxide gas, and 
for this reason should be given the preference over all 
others. 

A patient should be prepared for the administration of 
ether by not allowing him to have any solid food for at 
least six hours before its inhalation ; he should be in the 
recumbent posture, and any garments about the chest or 
neck should be loosened so that the respiratory movements 
are not interfered with. The surgeon should also see that 
any false teeth or foreign bodies which may be present in 
the mouth are removed before the administration of the 
drug is begun. As the vapor of ether often causes irrita- 
tion of the mucous membrane of the lips and nasal pas- 
sages, it is well to anoint these parts with a little vaseline 
or cold-cream before administering the ether. 

It should also be borne in mind that the vapor of ether 
is very inflammable, and that it is heavier than the air, so 
that lights brought near the patient while being etherized 
should be held at a higher level than the ether-can or 
inhaler. 

For the administration of ether a towel folded into a 
cone or one of the various ether inhalers may be employed. 
The best of these is Allis's inhaler (Fig. 145), which con- 
sists of a metallic framework covered with leather, which 
carries a number of folds of a roller bandage, giving a 
large surface for the rapid evaporation of the drug. 

If a towel folded into a cone is used, a few layers of stiff 
paper interposed between the outer layers of the towel will 
keep the cone in shape and will prevent the evaporation 
of the ether from its external surface. 



234 



MINOR SURGERY. 



In debilitated patients or those who are weak from the 
loss of blood the administration of half an ounce to an 
ounce of whiskey from fifteen to thirty minutes before the 
anaesthetic is given is often advisable. 

For the administration of an anaesthetic the patient 
should be in the recumbent posture and the head should 
be turned to one side, as in this position mucus is less apt 
to collect in the pharynx and interfere with the breathing. 



Fig. 145. 




Allis's ether inhaler. 

In administering ether, half an ounce of ether is poured 
over the inner surface of the towel or inhaler and it is 
brought near the mouth of the patient, and he is requested 
to take deep breaths or to blow the ether away, and as soon 
as he has become accustomed to the irritating qualities of 
the ether vapor the cone or inhaler is held firmly over 
the mouth and nose, and the vapor is administered in as 
concentrated a form as possible ; if the respiration and 
circulation are good, there is no disadvantage in pushing 
the ether. When the conjunctiva is insensible to the touch 
of the finger, and the muscular relaxation is complete, and 
the breathing tends to become stertorous, the stage of com- 
plete anaesthesia has been reached, and the ether should 
be withdrawn for a time or should be given only in such 
quantities as suffice to keep the patient in this condition. 



ETHER. 235 

The first effect from the inhalation of ether is to produce 
acceleration of the pulse and respiration ; the mucous mem- 
brane of the air-passages is irritated and coughing often 
occurs ; there is also in this stage a disposition to muscular 
movements, and it is frequently necessary to restrain the 
patient ; the brain is also excited and the patient is apt to 
cry out. These symptoms call for a continuance of the 
administration of the ether and not for its withdrawal. 
Succeeding this stage, if the ether is pushed, profound 
anaesthesia takes place, as is evidenced by loss of conscious- 
ness, relaxation of the muscular system, moistened skin, 
loss of the special senses, contracted pupils, and slow and 
deep respiration tending to become stertorous. 

Under the name of first insensibility from ether there 
exists early in the course of the administration of ether a 
primary anaesthesia, which lasts for a minute or so, and 
which may be taken advantage of to perform such minor 
surgical operations as the opening of an abscess or the 
reduction of a dislocation or the drawing of a tooth. The 
recovery from this condition is usually very prompt, and 
it is not followed by nausea and the after-effects which 
attend the prolonged administration of ether. During the 
administration of ether, particularly in the early stage, 
the patient may stop breathing, the face at the same time 
becoming cyanosed ; this condition calls for the withdrawal 
of the ether, and if a deep inspiration does not quickly 
follow, pressure should be made upon the front of the 
chest, and when this is relaxed a deep inspiration usually 
takes place and no further difficulty is experienced. 

If the patient has eaten solid food shortly before the 
etherization, vomiting is apt to occur ; when this takes 
place the ether inhaler should be removed and the head 
should be turned to one side, or the patient should be 
rolled upon his side, the mouth being kept open to facili- 
tate the escape of the vomited matters. The breathing 
also sometimes becomes obstructed by the accumulation of 
mucus in the fauces ; this should be removed by small 
sponges securely fastened to sponge-holders. 

When the anaesthesia is profound it sometimes happens 



236 



MINOR SURGERY. 



that the muscular relaxation is so complete that the tongue 
falls backward and the glottis is closed, the face becomes 
cyanosed and the pulse frequent and irregular, and death 
is threatened from asphyxia ; in this event the head should 
be extended and the lower jaw should be pressed forward 
by the fingers placed beneath the ramus of the inferior 
maxillary bone. (Fig. 146.) This manipulation is usually 
sufficient to re-establish the respiratory movements, but if 
so fortunate a result does not take place, artificial respira- 
tion should be practised — Laborde's, Sylvester's, or How- 
ard's method being given the preference — the patient's 

Fig. 146. 




Pushing the lower jaw forward. (Esmakch.) 

head being placed upon a lower level than the body, the 
tongue brought forward, and the fauces being cleared of 
mucus. The respiratory action should also be stimulated 
by the use of electricity — one sponge-electrode being placed 
over the sternum, the other being applied to the epigas- 
trium during an inspiratory effort. 

If artificial respiration is not satisfactorily applied in 
this way, forced respiration applied by means of a mask 
with tube and bellows attached (Fell's apparatus), or an 
intubation-tube with a rubber tube attached, which is 



ETHER. 237 

connected with a bellows, may be slipped into the larynx, 
and air may thus be directly forced into the lungs, or 
the trachea should be opened. Tracheotomy is especially 
to be recommended if the asphyxia has resulted from 
blood or vomited matters having entered the larynx. 
After opening the trachea and introducing a tracheal 
canula, a rubber tube and bellows are connected with this 
and respiratory movements are simulated by forcing air 
directly into the trachea. 

The hypodermic injection of strychnia, atropia, or digi- 
talis is also recommended, and the intravenous injection of 
ammonia is said to have been followed by good results. 

Efforts at resuscitation in these cases should be per- 
severed in for at least half an hour, as apparently hopeless 
cases have been saved by the persistent use of these means. 

The person intrusted with the administration of the 
anaesthetic should watch the patient closely and should not 
have his attention diverted by the operation ; he should 
carefully watch the pulse, respiration, and the color of the 
patients face, and be ready to withdraw the ether upon 
the development of any symptom of danger, and to meet 
such symptoms, should they arise, by the use of some of 
the means previously mentioned. 

The administration of ether vapor by the rectum was a 
few years ago employed in many cases, and although anaes- 
thesia w r as quickly produced, dangerous symptoms some- 
times followed its employment, so that this method of 
administration has been abandoned. 

Vomiting after the administration of ether is very com- 
mon, and if it persists after a few hours, it may be relieved 
by the administration of the fourth of a grain of cocaine 
with crushed ice, repeated two or three times, or by the 
use of crushed ice with champagne or brandy, and in some 
cases the swallowing of a few mouthfuls of very warm 
water will relieve this condition. 

An anaesthetic should never be given to a woman with- 
out the presence of a third person, as in some cases these 
agents give rise to erotic dreams, and it may be difficult 
to disabuse the patient's mind of the idea that an assault 

11* 



238 MINOR SURGERY. 

has been committed unless the evidence of eye-witnesses 
at the time of the anesthetization can be brought forward 
to prove that such was not the case. 

Chloroform. 

A patient is prepared for the administration of chloroform 
as in the case of ether, the same precautions being taken as 
regards the removal of false teeth or foreign bodies from 
the mouth, and to see that the clothing about the chest and 
neck does not restrict the circulation or respiratory move- 
ments. Chloroform is certainly a much more dangerous 
anaesthetic than ether, and although it is widely used in 
the British Islands and upon the Continent, it is not used 
in this country except in certain districts — as in the 
southern and southwestern districts of the United States, 
and here its use is followed by fewer fatalities than in the 
northern districts, so that it is possible that its use is safer 
in warm climates. Clinical experience has demonstrated 
the fact that chloroform can be used in aged and very 
young subjects and in puerperal patients with comparative 
safety ; it is also to be preferred to ether in patients suffer- 
ing from emphysema of the lungs, bronchitis, and vascular 
degeneration of the kidneys. It is also employed instead 
of ether in operations upon the mouth when the actual 
cautery is employed, on account of its less inflammable 
character. 

The result of clinical experience and the deductions from 
physiological experiments seem conclusively to point to 
the fact that chloroform is a direct depressant and paraly- 
zant of the heart muscle. 

Chloroform is administered by pouring a drachm of the 
drug upon a folded towel, which is first held a few inches 
from the mouth and nose and gradually brought nearer, 
but is not allowed to come in contact with the face, as from 
its local irritating action it will blister the surface ; the 
ansesthetizer should remember that one of the dangers in 
the administration of chloroform is the risk of too great 



CHLOROFORM. 



239 



concentration of its vapor, so that he should see that a 
sufficient admixture of atmospheric air takes place. Pro- 
found anaesthesia is evidenced by insensibility of the con- 
junctiva to the touch, by complete muscular relaxation, 
and by the absence of reflexes ; the pupils in chloroform- 
anaesthesia are usually contracted. Various inhalers have 
been devised to regulate the amount of chloroform admin- 
istered and to secure the proper admixture of atmospheric 
air, and the best of these is probably Mr. Clover's appa- 
ratus. (Fig. 147.) This consists of a bag holding 8000 



Fig. 147. 




Clover's chloroform apparatus. (Eeichsen.) 

cubic inches of air connected with a face-piece by a flexible 
tube. The bag is charged by means of a bellows (Fig. 
147, 1) measuring 100 cubic inches ; and the air is passed 
through a box warmed with hot water, into which is intro- 
duced at each filling of the bellows as much chloroform as 
is required for 1000 cubic inches of air. This is done 
with a syringe (Fig. 147, 2); the amount of chloroform 
required is usually from 30 to 40 minims. When the 
bag is full the tube is removed from the evaporator and 
the mouthpiece (Fig. 147, 3) is fitted to it. Additional 
air may be admitted by regulating the size of the opening 



240 MINOR SURGERY. 

in the mouthpiece ; the patient, however, cannot receive a 
larger proportion of chloroform than the air in the bag is 
charged with. 

Death from the administration of chloroform results 
from cardiac syncope or from respiratory arrest, and the 
dangerous symptoms develop so rapidly that the greatest 
promptness is required to meet them. The person ad- 
ministering chloroform should constantly watch both the 
pulse and the respiration, and should not for a moment 
have his attention diverted from the patient ; great vigi- 
lance is here, if possible, more important than during the 
administration of ether. 

When dangerous symptoms arise they are to be treated 
by lowering the patient's head, and if respiratory arrest 
has occurred, the same means to bring about respiratory 
action should be employed as for a . similar condition 
during ether narcosis. Cardiac syncope is treated by the 
use of electricity, the electrodes with a rapidly interrupted 
current being swept over the chest ; hypodermics of digi- 
talis and strychnia and atropia may be employed to stimu- 
late the heart and respiration, and as in ether narcosis the 
efforts should not be desisted from for some time, as by the 
persistent employment of these means apparently hopeless 
cases have been resuscitated. 

The A.-C.-E. Mixture. 

This mixture, which consists of 3 parts of chloroform, 
1 part of ether, and 1 part of alcohol, has been employed 
by some surgeons in the place of ether or chloroform, with 
the idea that the dangers of chloroform are diminished by 
its combination with ether and alcohol. Clinical ex- 
perience, however, has not proved this view to be correct, 
and I see no advantage in the use of this combination over 
that of ether or chloroform. If administered with as much 
care as chloroform, its administration is accompanied with 
the same safety. It should be administered upon a towel 
in the same manner as chloroform, and the patient should 
be watched as carefully during its inhalation as during the 



TBUSSES. 241 

administration of the latter drug, any complication occur- 
ring should be treated in the same manner as those arising 
during the use of chloroform. 

Bromide of Ethyl. 

This drug was introduced as an anaesthetic some years 
ago, but as a number of deaths followed its use, it was 
abandoned. The time required to produce anaesthesia is 
shorter than for ether, but there is often induced violent 
muscular spasm, which renders it an unsuitable anaesthetic 
in many cases. 

Bromide of ethyl has again been revived as an anaes- 
thetic, but clinical experience has found that its use is not 
devoid of danger, that it is not as safe an anaesthetic as 
ether, and that it possesses no advantages in point of safety 
over chloroform. When used it should be administered 
by pouring a drachm or two upon an inhaler or a towel, 
and the patient should be watched with the same care as 
during the administration of chloroform. 



Trusses. 

A truss for the palliative treatment of hernia is a me- 
chanical contrivance with one or more pads and a strap ; 
these are held in position by a spring to which they are 
attached, which holds the pad in contact with the skin 
over the hernial ring. 

They are applied in all cases of reducible hernia, and 
are used in the treatment of hernia at all ages ; in infants 
and young children the continued use of a properly fitting 
truss is often followed by a radical cure of the hernia. 

Trusses are made with steel or rubber rings and with 
pads of wood, rubber, celluloid, or horsehair, covered with 
chamois, and their shape and the pressure which they 
should exert vary with the variety of hernia for which 
they are applied. 

A firm compress applied over the inguinal canal or crural 



242 MINOR SURGERY. 

ring, secured in position by a firmly applied spica-of-the 
groin bandage, forms a very satisfactory temporary means 
of preventing the descent of a hernia. 

A properly fitting truss should be worn without discom- 
fort to the patient — that is, should not make too much 
pressure upon the skin at the points where the pads are 
applied — and should absolutely prevent the descent of the 
hernia. In testing the adequacy of a truss, after appli- 
cation, to prevent the escape of the hernia, the patient 
should be instructed to separate his legs, bend forward 
over the back of a chair, and cough or strain deeply ; if 
this does not bring the hernia down, its control of the rup- 
ture may be considered satisfactory. 

Trusses should be applied after the complete reduction 
of the hernia, while the patient is in the recumbent pos- 
ture. When first applied the truss should be worn both 
during the night and day, and if the skin becomes tender 
at the points of pressure, it should be sponged with alcohol 
and alum, then dried and dusted with powdered starch or 
lycopodium. Patients at first sometimes complain of dis- 
comfort in wearing a truss, but they soon become accus- 
tomed to its presence. After a truss has been worn for 
some time its use at night, while the patient is in bed, 
may be dispensed with, but the patient should not remove 
it until he is in bed in the recumbent posture, and he should 
reapply it before he rises in the morning. In children it 
is better to have the truss worn continuously, and if it is 
removed for bathing the nurse should be instructed to 
place her finger over the ring to prevent the descent of the 
hernia until the truss is reapplied. In applying trusses 
to male children care should be taken not to make pressure 
upon an undescended testicle. 

Trusses for Inguinal Hernia. 

In measuring a patient for this form of truss the cir- 
cumference of the body midway between the crest of the 
ilium and the great trochanter should be taken, and the 



TRUSSES FOR FEMORAL HERNIA. 



243 



distance from the symphysis pubis to the anterior superior 
spinous process of the ilium may also be given, as half of 
this distance corresponds to the position of the internal 
abdominal ring. In reducible inguinal hernia the truss- 
pressure should be exerted upon the inguinal canal and 



Fig. 148. 




Truss for inguinal hernia. 



directly backward. To control this variety of hernia a 
single-spring truss (Fig. 148) may be employed, or the use 
of a truss having a double spring with flat pads on each 
side of the spine attached to the springs, and a smaller 
pad over the inguinal canal on the unaffected side, with a 



Fig. 149. 




Hood's truss. 



full pad on the side of the hernia, will often be found 
most satisfactory. This, which is known as Hood's truss, 
is one w^hich will be found a very satisfactory instrument 
both in inguinal and femoral hernia. (Fig. 149.) 



Trusses for Femoral Hernia. 



In measuring a patient for this variety of truss, the cir- 
cumference of the body midway between the crest of the 
ilium and the great trochanter should be taken ; the dis- 



244 



MINOR SURGERY. 



tance of the saphenous opening from the symphysis pubis, 
as well as from the anterior iliac spine, should also be 
taken. In reducible femoral hernia the truss-pressure 
should be directed backward against the femoral canal, 
and the pad should be large enough to make pressure upon 
the adjacent tissues through which the hernia passes, as 
well as upon the relaxed tissues covering the femoral canal. 
As in inguinal hernia, either a single or a double spring 
truss may be employed (Fig. 150). 

In applying a truss for femoral hernia, care should be 
taken to see that the pad does not rest upon the pubis, and 
thus remove the pressure from the crural ring and adja- 
cent tissues and prevent the proper control of the hernia. 

Trusses for Umbilical Hernia. 

In measuring a patient for this variety of truss, the cir- 
cumference of the body over the umbilicus should be taken. 



Fig. 150. 



Fig. 151. 




Hood's truss for femoral hernia. 



Truss for umbilical hernia. 



In reducible umbilical hernia the truss-pressure should 
be directed backward, and the pad should bear rather on 
the tendinous margins of the ring than on the hernial 
opening. A truss for this variety of hernia should have a 
flat or slightly convex pad, which is held in position over 
the umbilical ring by means of springs having counter- 
pads on either side of the spine attached to their extremi- 
ties ; these are fastened together by a strap (Fig. 151). 

A simple and satisfactory truss for umbilical hernia in 
infants consists of a penny covered by adhesive plaster, 
held over the umbilical ring by one or two strips of adhe- 
sive plaster about two inches in width, and should be 



USE OF CATHETERS AND BOUGIES. 245 

applied so as to cover in about the anterior two-thirds of 
the body. A penny, or a small, flat, compress of linen, 
will be found much more satisfactory than the conical 
rubber or cork pad which is often recommended. 

Trusses for Irreducible Hernia. 

The application of a truss to this variety of hernia 
secures the hernia from injury and prevents the further 
protrusion of the hernia ; such trusses are secured in the 
same way as those for reducible hernia, but the pads are 
made concave or cup-shaped, or may have an air-cushion 
attached to the pad. 



Use of Catheters and Bougies. 

Catheters are hollow tubes, made either of metal, India- 
rubber, or other flexible substances. 

Metallic catheters are made of silver, or, if constructed 
of other metals, they should be plated with silver or nickel, 
to give them a smooth, bright surface which can easily be 
kept perfectly clean ; and their shape should conform to 
that of the normal urethra (Fig. 152). The shape of the 
metallic catheter is sometimes changed to meet certain 
indications ; for instance, the metallic catheter for use in 
cases of enlarged prostate is longer and has a larger curve 
than the ordinary instrument (Fig. 153). The metallic 
female catheter is shorter and has a much smaller curve 
than the instrument used for the male urethra. 

Flexible Catheters. — The most commonly used variety of 
flexible catheter is that known as the English catheter, 
which is made of linen and shellac, and is provided with 
a stylet ; it can be moulded into any shape desired by dip- 
ping it into hot water, which renders it very flexible, and, 
after moulding it to the proper curve, this can be fixed by 
immersing it in cold water, which hardens it again. 



246 



MINOR SURGERY. 



The French flexible catheters are made of India-rubber, 
or a combination of this material with other substances. 



Fig. 153. 



Fig. 152. 



Metallic catheter. 



Prostatic catheter. 



These instruments are conical toward their extremities, and 
terminate in an olive-shaped point; they are provided 
with one or two smoothly finished eyes near their vesical 
extremities (Fig. 154). 

Another form of flexible catheter, known as the elbow T - 
catheter or Mercier's catheter (Fig. 155), has an angle or 



BOUGIES AND SOUNDS. 



247 



elbow near its vesical extremity ; this is often found a 
satisfactory instrument to use in cases of enlarged prostate. 



Fig. 154. 




French flexible catheters. 
Fig. 155. 

Mercier's elbowed catheter. 



A variety of flexible catheter made of soft India-rubber 
is also sometimes employed. (Fig. 156.) 



Fig. 156. 




Soft rubber catheter. 



Catheters and bougies are made according to a certain 
scale. The English scale runs from l.to 12; the American 
from 1 to 20 ; and the French from 1 to 30. 



Bougies and Sounds. 

Bougies are flexible instruments which correspond in 
size and shape to the English and French catheters, and 
besides there are the acorn-pointed bougie (Fig. 157) and 



248 



MINOR SUBGERY. 



the filiform bougie, which is made of whalebone or of the 
same material as the ordinary French bougie and catheter. 
These instruments are of very small size and can often be 



Fig. 157. 




Bulbous or acorn-pointed bougies. 
Fig. 159. 



Fig. 160. 



Fig. 158. 



{/ 



Filiform bougies. 



Steel sound. 



Sound for dilating meatus. 



INTRODUCTION OF A CATHETER. 249 

passed through strictures which will admit no other form 
of instrument. (Fig. 158.) 

Sounds. — These are solid instruments usually made of 
steel with a smooth surface and plated with nickel ; they 
correspond in size and have the same curve as the metallic 
catheter ; the handle is flattened to allow the operator to 
grasp them firmly ; they are employed in the treatment of 
strictures by dilatation. (Fig. 159.) The sound used in 
dilating strictures of the meatus is straight and is shorter 
than the sound employed in the treatment of urethral 
strictures. (Fig. 160.) 



Introduction of a Catheter. 

The passing of a catheter is a minor surgical procedure 
which every practitioner is at times called upon to employ, 
and its passage through a healthy urethra is a matter of 
little difficulty. For the introduction of a catheter the 
patient may be in the standing, sitting, or recumbent pos- 
ture, and the latter is the best in most cases ; he should 
rest squarely on his back and have the thighs a little flexed 
and separated. 

Before passing a metallic catheter the surgeon should 
see that it is perfectly clean, and after warming and oiling 
it he stands upon the left side of the patient and grasps 
the penis with the left hand, and turns it over the pubis 
and introduces the beak of the catheter into the meatus, 
and gently passes it along the urethra until its point passes 
beneath the symphysis pubis ; at this point the handle is 
elevated and gently depressed between the thighs, and the 
beak will pass into the bladder. (Fig. 161.) 

When the prostatic region is reached difficulty is some- 
times experienced in the further passage of the instrument ; 
this may be overcome by introducing the finger into the 
rectum and guiding the catheter through the prostatic 
urethra, or if the prostate is found much enlarged, the 
catheter should be withdrawn, and a prostatic catheter 
(Fig. 153) should be substituted for it. 



250 



MINOR SURGERY. 



The same manipulation is made use of in passing 
metallic sounds. 

Flexible catheters and bougies are passed by grasping 
the penis and holding it in such a position that it is at a 
right angle to the axis of the body, and the catheter or 



Fig. 161. 




Introduction of a catheter. (Voillemiee.) 



bougie is passed into the meatus and carried through the 
urethra into the bladder by gently pushing the instrument 
downward. 

In this variety of catheter, which has no curve, the sur- 
geon has no means of guiding the. point of the instrument, 
and if an obstruction is met, he should withdraw the instru- 



TYING THE MALE CATHETER IN THE BLADDER. 251 

ment slightly and make another attempt ; all manipulations 
should be extremely gentle. 

The same manipulations are employed in passing 
bougies through the urethra. 

Passing the Female Catheter. 

This should be introduced without exposure of the 
patient, she being in bed with the thighs slightly flexed 
and separated from each other. The surgeon introduces 

Fig. 162. 




Method of holding the female catheter. 

the forefinger of the left hand between the nymphse, bring- 
ing it from behind forward until he touches the space 
between the entrance of the vagina and the orifice of the 
urethra ; the catheter is then introduced with the right 
hand held as shown in Fig. 162, and guided by the left 
forefinger is passed through the orifice of the urethra into 
the bladder. 

Tying the Male Catheter in the Bladder. 

When it is desirable to retain a catheter for some time 
in the male bladder, it is necessary to secure it to prevent 
its slipping out. Either a metallic or flexible catheter 
may be employed, but, as a rule, the flexible instrument is 
to be preferred ; there are several methods of securing it 
in the bladder. 

By one method two narrow strips of tape or two or 




252 MINOR SURGERY. 

three strong silk ligatures are attached to the rings at the 
end of a metallic catheter, or are securely fastened around 

the end of the flexible instru- 
FlG - 163 - ment ; these are next brought 

backward, one on each side of 
the penis, and the skin is drawn 
forward and a strip of adhesive 
plaster half an inch in width 
is passed over the strings or 
tapes and carried three or four 
times around the body of the 

Tying in catheter. (Bryant.) penis just behind the position 

of the glans penis. If the skin 
has been brought well forward before the strips have been 
applied, the ligatures are tightened as it slips back, and 
the catheter has not too much play. (Fig. 163.) 

Another method consists in fastening a strong silk liga- 
ture around the catheter just in advance of the meatus ; 
the two ends are next brought backward and tied in a 
knot behind the corona glandis ; the ends are then carried 
around behind the corona and tied on one side of the 
frsenum ; the foreskin is slipped forward and covers the 
ligatures, 

A catheter may also be secured in the bladder by tying 
the ends of the silk ligatures, which are attached to the 
instrument in advance of the meatus, to tufts of pubic hair. 

A simpler method of securing the catheter is to perforate 
the free end with a needle armed with a double ligature 
of silk or hemp ; the needle being removed, two loops are 
made of the proper length, and these are passed through 
the ends of a T-bandage, which is secured around the 
waist, the tails being brought up on either side of the 
scrotum and secured to the body of the bandage passing 
around the waist. 

In the female bladder, when it is desirable to keep the 
bladder empty, the self-retaining catheter is usually em- 
ployed, which consists of a catheter with a bulb at its 
vesical extremity, or an ordinary catheter with silk loops 



URETHRAL INJECTIONS. 253 

and a T-bandage may be employed in the same manner as 
in securing a male catheter. 

Washing out the Bladder. 

This procedure may be required in the treatment of 
cystitis, and it is accomplished by passing a flexible 
catheter with a large eye into the bladder, or a double 

Fig. 164. 




Rubber bag with stopcock, for washing out the bladder. 

catheter may be employed. A syringe, or better a rubber 
bulb holding about a pint, having a nozzle and stopcock 
(Fig. 1 64), is filled with warm water, or with any medi- 
cated solution which is desired, and it is then attached to 
the free end of the catheter and the contents are gently 
injected into the bladder ; care should be taken that the 
bladder is not too much distended. When the desired 
amount of fluid has been injected, it is allowed to run out 
of the catheter, and the procedure may be repeated until 
the solution comes away perfectly clear. 

Care should be taken to see that the bladder is perfectly 
emptied of the solution, and in cases of paralysis of the 
bladder gentle pressure should be made upon the abdomen 
over the pubis to accomplish this object. Solutions of 
boric acid, permanganate of potassium, and weak solutions 
of carbolic acid and of nitrate of silver are often employed 
in washing out the bladder in cases of chronic cystitis. 

Urethral Injections. 

In the treatment of urethral inflammations the injection 
of medicated solutions is generally made use of, and as 

12 



254 



MINOR SURGERY. 



,165. 



these injections are usually made by the patient himself, 
he should be shown or instructed how to employ them. 
A rubber syringe having a conical nozzle and 
holding about two or three drachms is the 
best instrument to employ for this purpose. 
(Fig. 165.) The syringe having been filled 
with the solution, the patient sits upon the 
edge of a hard chair, with the thighs sepa- 
rated, grasps the syringe between the thumb 
and middle finger of the right hand, the tip of 
the index finger resting upon the end of the 
piston, and inserts its conical end from a quarter 
to half an inch within the meatus, which is held 
open by the thumb and finger of the left hand. 
After the introduction of the nozzle of the 
syringe the tissues should be drawn tightly 
around it, the pressure being made laterally so 
shape ot ag ^ Q narrow ^he urethral opening; instead of 

nozzle of ^ 

urethral broadening it, as is the case when the compres- 

syringe. sion is in an antero-posterior direction. After 

the fluid has been thrown into the urethra in 

this manner the syringe is removed, and the patient is 

instructed to hold the lips of the meatus together for one 

or two minutes to prevent the escape of the fluid. 




Sutures. 



A variety of materials are employed for sutures, such as 
silk, catgut, silver or iron wire, silkworm-gut, kangaroo- 
tail tendon, and horsehair ; the material most frequently 
employed at the present time is either catgut, silk, or silk- 
worm-gut, although some surgeons still prefer silver wire. 
Catgut and kangaroo-tail tendon are practically the only 
substances employed as sutures which are absorbable ; the 
other varieties of suture require removal after their appli- 
cation, although some sutures, such as the silk, when 
employed in subcutaneous w 7 ounds may be cut short, as 
they are apt to become encysted and produce no trouble. 



SURGICAL NEEDLES. 255 

It matters little what variety of material be employed for 
suturing if the surgeon is careful to see that it is rendered 
thoroughly aseptic before being brought in contact with 
the wound. 

Sutures of Relaxation are those which are entered and 
brought out at some distance from the edges of the wound, 
and are employed to prevent dangerous tension upon the 
sutures which approximate the edges of the skin. This 
form of suture is employed by the use of the quilled, 
button, or plate suture. 

Sutures of Coaptation. — These are superficial sutures 
applied closely together and include only the skin \ they 
are employed to secure accurate apposition of the cutaneous 
surface of wounds. 

Sutures of Approximation are those which are applied 
deeply into the tissue to secure approximation of the deep 
portions of a wound ; this object is accomplished by the 
use of the quilled, button, or plate suture. 

Secondary Sutures. — These sutures are applied when the 
surfaces of the wound are covered by granulations, when 
the primary sutures have failed to secure apposition of the 
edges of the wound, or in cases of secondary hemorrhage 
where the opening of the wound has been necessitated to 
turn out the blood-clot and secure the bleeding vessel, or 
in plastic operations where the primary sutures have failed 
to secure adhesions of the edges of the flaps. They are 
also employed with advantage in cases in which it is neces- 
sary to pack a wound with antiseptic gauze, or to allow 
haemostatic forceps to remain clamped upon bleeding tissues 
in a wound at the time of operation. The sutures should 
in such a case be introduced and loosely tied at this time, 
and when the packing or forceps is removed at the end 
of two or three days the sutures are tightened so as to 
secure apposition of the edges of the wound. 

Surgical Xeedles. 

Xeedles for surgical use are of different sizes and shapes 
(Fig. 166) ; straight needles are the ones most commonly 



256 MINOR SURGERY, 

employed, but curved needles will be found most con- 
venient for the introduction of sutures in wounds of certain 

Fig. 166. 




<z^gs^ 



Surgical needles. 



locations. Hagedorn needles, which are flat and have sharp- 
cutting edges, make a narrow linear wound in the tissues 



Fig. 167. 




Mounted needle. 



and are useful in some cases. Tubular needles are often 
employed in introducing sutures in wounds in which the 



Fig. 168. 




Needle-holder. 



use of an ordinary needle is difficult : for instance, in the 
operation for cleft palate, and for the introduction of sutures 



SECURING SUTURES AND LIGATURES. 257 

in deep wounds, a mounted needle will often be found very 
useful (Fig. 167). Xeedles should be sharp and clean and 
should be rendered thoroughly aseptic before being used. 
A needle-holder is often required for the satisfactory intro- 
duction of sutures in wounds of certain localities (Fig. 
168) ; if this is not at hand the needle may be held by a 
pair of dressing forceps or a pair of haemostatic forceps. 



Method of Securing Sutures and Ligatures. 

Metallic sutures are usually secured by twisting the 
ends together or by passing the ends through a perforated 
shot and clamping the shot with a shot-compressor, which 
securely fixes them. 

Sutures and ligatures of catgut, silk, silkworm-gut, 
kangaroo-tail tendon, or horsehair are secured by tying, 
and several different knots are employed to secure them. 

Reef or Flat Knot 

Fig. 169. 




Reef or flat knot. 



This is one of the best forms of knot to use in securing 
sutures or ligatures, and it is made by passing one end of 
the thread over and around the other end, and the knot 
thus formed is tightened ; the ends of the thread are next 
carried toward each other and the same end is again car- 
ried over and around the other, and when the loop is drawn 
tight we have formed the reef or flat knot (Fig. 169). 



258 MINOR SURGERY. 



Surgeon s Knot 

This knot is formed by carrying one end of the thread 
twice around the other end (Fig. 170) ; and after tighten- 

FlG. 170. 




Surgeon's knot. 

ing this loop the same end is carried over and around the 
other end as in the case of the final knot of the reef or flat 

Fig. 171. 




Surgeon's knot and reef knot combined. 

knot. The surgeon's knot and reef knot combined is one 
of the best methods of securing sutures or ligatures of 
catgut or silk, as the first knot is not apt to relax before 
the second knot is applied. (Fig. 171.) 

Granny Knot. 

This method of tying the ligature or suture should not 
be employed, as the resulting knot is not as secure as the 
reef knot and is apt to relax ; it differs from the latter in 
the fact that one end of the thread having been carried 
across and around the other end, the knot is completed by 
ca^ying the same end under and around the other end ot 
tho thread (Fig. 172). 



VARIETIES OF SUTURE. 259 

The Staffordshire knot, which is much used to secure the 
pedicle in the removal of the ovaries or ovarian tumors, is 
applied as follows : A handled needle armed with a stout 
silk ligature is passed through the pedicle, and then with- 

FiG. 172. 




Granny knot. 



drawn so as to leave a loop on the distal side ; this loop is 
drawn over the ovary or tumor and one of the free ends 
is passed through it so that one end is above while the 
other end is below the retracted loop. (Fig. 173). The 



Fig. 173. 




Staffordshire knot. 

ends are then seized and drawn through the pedicle ; at the 
same time the thumb and forefinger are pressed against it 
until sufficient constriction is made, and the ends are finally 
secured by tying as in the securing of an ordinary ligature. 

Varieties of Suture. 

The Interrupted Suture. 

This variety of suture is the one most usually emplcved 
in the apposition of wounds, which consists of a nun. >er 



260 MINOR SURGERY. 

of single stitches, each of which is entirely independent of 
those on either side. In applying this suture the surgeon 
holds the edge of the wound with the fingers or forceps 
and thrusts the needle, previously threaded, through the 
skin three or four lines from the edges of the wound. He 
then passes the needle from within outward through the 
tissues of the opposite flap at the same distance from the 
edge of the wound. (Fig. 174.) Each stitch is secured 

Fig. 174. 



The interrupted suture. 



as soon as it is passed — by tying if a silk, catgut or silk- 
worm-gut suture be used, or by twisting if a silver-wire 
suture is employed. A suture may be used with a needle 
threaded on each end, in which case both needles are 
passed from within outward. The sutures may be secured 
as soon as applied, or they may be left unsecured until a 
sufficient number have been introduced, and then they may 
be secured by tying or twisting. Care should be taken to 
see that they make no tension on the edges of the wound 
and that they are so introduced as to make the best possi- 
ble apposition of the parts. 

Buried Sutures. 

In extensive and deep wounds it may be found neces- 
sary to introduce both deep and superficial sutures, the 
former bringing about apposition of the muscles and deep 



VARIETIES OF SUTURE. 



261 



fascia, the superficial layer bringing together the superficial 
fascia and skin. 

The deep or buried sutures are often employed to unite 
fascia, muscles, or tendons, and the best material for this 
variety of suture is either catgut, silk, silkworm-gut, or 
kangaroo-tail tendon. 

Continued or Glover's Suture. 

This variety of suture is applied in the same manner as 
the interrupted suture, but the stitches are not cut apart 
and tied ; it is made with silk or catgut and is secured by 
drawing it double through the last stitch and using the 

Fig. 175. 




Continued or glover's suture ; method of securing. 

free end to make a knot with the double portion attached 
to the needle. (Fig. 175.) This suture is generally em- 
ployed in intestinal sutures, but also may be employed in 
bringing about apposition of the edges of wounds 
tissues of loose structure. 

12* 



in 



262 



MINOR SURGERY. 



Subcuticular Suture. 

Halstead has introduced a suture in which the needle is 
introduced on the under surface of the skin on one side, 
and brought out just beneath the cut edge ; it is then entered 
in the reverse direction below the epidermic surface oppo- 
site ; when tied it will lie wholly out of sight. The object 
of this variety of suture is to avoid infection of the wound 
by the skin coccus which may be introduced by the suture 
if passed from without inward. Fine silk or catgut should 
be used for this variety of suture, which may become en- 
cysted, absorbed, or gradually cast off after a few weeks. 

The Twisted or Hare-lip Suture. 

This is a very useful form of suture where great accuracy 
and firmness of apposition of the edges of the wound are 
desired. It is applied by thrusting pins or needles deeply 
through both lips of the wound, the edges being kept in 
contact over the wound by figure-of-eight turns with silk 
or wire. (Fig. 176). The ends of the pins should be cut 



Fig. 176. 



Fig, 177. 





Twisted or hare-lip suture. 



India-rubber suture. 



off by pin-cutters after the sutures are applied, or should 
be protected by pieces of cork or plaster to prevent them 
from injuring the skin of the patient and causing him 
pain. 

The twisted or hare-lip suture is frequently employed 
in plastic operations about the face and in other parts ot 
the body where accurate apposition of the flaps is desired. 



VARIETIES OF SUTURE. 



263 



The India-rubber Suture. 

This is applied by first passing the pins or needles 
through the edges of the flaps, and instead of the twisted 
figure- of-eight suture of silk, delicate rings of India-rubber 
are employed. (Fig. 177.) 

Tlie Quilt Suture. 

This variety of suture is made with silk or catgut, and 
is employed in wounds to effect very close approximation 

Fig. 178. 




The quilt suture. 



of the parts and to prevent bagging ; it is often employed 
in connection with the continued suture, and is applied as 
shown in Fig. 178. 



264 



MINOR SURGERY. 



The Quilled Suture. 

In making use of this suture a needle armed with a 
double thread of wire or silk is passed through the tissues 
as in applying the interrupted suture, but at a greater dis- 
tance from the edges of the wound. Into the loops on one 
side of the wound is inserted a quill or piece of a flexible 
catheter or bougie, and on the opposite side the free ends 
of the sutures are tied around a similar object after being 
tightened. (Fig. 179.) This form of suture makes deep 
and equable pressure along the whole line of the wound. 

Fig. 179. 







The quilled suture. (Smith.) 

In applying this suture it may be found advisable in some 
cases to introduce a few superficial interrupted sutures 'along 
the line of the wound to secure accurate approximation ot 
the skin. 

This form of suture was formerly much employed in 
cases of deep wounds to secure accurate apposition of the 
deep portions of the wound, but recently the introduc- 
tion of buried catgut sutures has supplanted the use of 
this variety of suture. 

Button or Plate Suture. 

This suture is applied by passing a needle armed with 
a double thread as in the case of the quilled suture, the 



VARIETIES OF SUTURE. 



265 



Fig. 180. 



ends of the suture being passed through the eyes of a 
button or through perforations in a lead plate before 
being threaded in the eye of the needle. 
After the suture prepared in this way 
has been passed through both sides of the 
wound, the needle is removed and the 
free ends of the suture are passed through 
the eyes of a button or the perforations 
in a lead plate on the opposite side of the 
wound, and are tightened and secured. 
(Fig. 180.) This form of suture may be 
employed in deep wounds to accomplish 
the same purpose as the quilled suture. 
It allows the cutaneous margins of the 
wound to remain free from compression, 
and here, as in the case of the quilled 
suture, a few interrupted sutures may be introduced be- 
tween the button or plate sutures to secure accurate appo- 
sition of the skin surfaces it desired. 




Button suture. 
(Smith.) 



Fig. 181. 



Tongue-and-groove Suture. 

This variety of suture, devised by the late Dr. Joseph 
Pancoast, consists in slipping the margin of the flap which 
has been bevelled into a groove, 
made by dissecting up the mar- 
gin of the skin surrounding 
the raw surface which is to be 
covered. In applying this su- 
ture the wire or thread used 
has a needle applied on each 
end, and after passing the su- 
tures so as to secure the flaps 
the free ends are secured over a pad of adhesive plaster or 
a disk of lead or through the eyes of a button. (Fig. 181.) 

Shotted Sutures. 

This suture receives its name not from any special 
method of application, but solely from the way in which it 




Tongue-and-groove suture. 



266 MINOR SURGERY. 

is secured ; any of the previously mentioned varieties of 
sutures may be employed. The material used in applying 
this suture may be catgut, silver wire, silkworm-gut, silk, or 
horsehair, and after the suture has been passed the needle 
is removed, and the ends are passed through a perforated 
shot ; the ends are then drawn upon to bring the edges of 
the wound in contact, and the shot is pressed down to the 
skin and clamped by means of a shot-compressor. The 
suture is then cut off' flush with the surface of the shot. 

This method of securing sutures is especially useful in 
closing wounds in the mucous cavities, such as the vagina, 
rectum, and mouth, where the knot or twist of the wire 
might cause irritation of the surface or pain to the 
patient • it is also a useful method of securing sutures in 
plastic operations ; it also facilitates the removal of the 
sutures, as the shot is not apt to be obscured by the 
swollen tissue, and is easily seized by forceps when the 
loop is divided. 

Removal of Sutures. 

Where sutures are buried in the tissues or used to ap- 
proximate parts in cavities which are subsequently closed, 
such materials should be used for sutures as will be ab- 
sorbed in a few days, or will become encysted and remain 
harmless in the tissues — such as catgut, silkworm-gut, or 
silk — and it is needless to state that sutures used with this 
end in view should be rendered perfectly aseptic before 
being employed. 

Catgut sutures, when well prepared and used for sutures 
in external wounds, usually undergo absorption in from 
ten to fifteen days ; the loop buried in the tissues is 
absorbed and the knot may be removed from the surface 
with forceps or it may come off with the dressings. 

The other substances, such as silk, silkworm-gut, silver 
wire, and horsehair, are removed by cutting one side of 
the loop and making traction upon the knot of the suture 
with forceps, or in the case of the wire suture, after divid- 
ing the loop and straightening out one end of it, the wire 
should be withdrawn in a curved direction. 



VARIETIES OF SUTURE. 



267 



Sutures which are not causing any irritation should be 
allowed to remain in position until the wound is solidly 
healed. The time usually required for their retention in 
cases of aseptic wounds is from eight to twelve days. 



Lemberfs Suture. 

Lembert's suture is used in wounds of the viscera 
covered by the peritoneum, with the object of bringing in 
contact the peritoneal surfaces. This form of suture is 

Fig. 182. 




Lemberfs suture. (Bryant.) 



usually employed in closing wounds of the intestine, blad 
der or stomach. (Fig. 182.) 



Fig. 183. 




Lembert's suture, a, serous ; b, muscular ; and, c, mucous coat. (Smith.) 

A needle armed with a fine catgut or silk thread is 
passed, and it is better to employ a round needle, such as 



268 MINOR SURGERY. 

the ordinary sewing-needle, in preference to the bayonet- 
pointed needle, as there results by its use less bleeding 
from the punctures. The needle is first carried through 
the peritoneal and muscular coats of the intestine a short 
distance from the wound, and it is then carried across the 
wound and passed through the same portions of the 
intestine a short distance from the edge of the wound on 
the opposite side, and when the suture is tightened the 
peritoneal surfaces of the intestine are inverted and 
brought into contact with each other (Fig. 183) ; the in- 
terrupted or continued suture may be employed in mak- 
ing this form of suture. 

Halstead's Quilt Suture. 

This is a modification of Lembert's method. The needle 
penetrates the superficial coats of the gut twice on each side 
of the wound, and is then tied. (Fig. 184.) 

Fig. 184. 




Halstead's quilt suture for intestines. 



GMy's Suture. 



In applying this form of suture in intestinal wounds a 
ligature armed with a fine needle at each end is employed, 



VARIETIES OF SUTURE. 
Fig. 185. 



269 





Gely's suture. 

and the punctures should be about five millimetres apart; 
the method of applying the suture is shown in Fig. 185. 

Bouisson's Suture. 

This method of suturing intestinal wounds, which is 
more complicated than either of the previously mentioned 
methods and possesses no advantage over them, is applied 

Fig. 186. 




Bouisson's suture. 



by passing a delicate pin in and out along each side of the 
wound as shown in Fig. 186, and drawing them together 
laterally by ligatures passed through the intervals, one 
end of each ligature being cut short and the other end 



270 MINOR SURGERY. 

being brought out at the lower angle of the external wound ; 
a thread is also tied under the head of each pin and brought 
out at the upper angle of the wound, and at the end of 
three or four days the pins are removed by means of the 
threads attached to them, and at the same time the sutures, 
having been freed by the removal of the pins, are withdrawn. 

Czerny Suture. 

This suture is applied in intestinal wounds by passing 
the needle armed with a catgut or silk thread through the 
serous membrane on one side of the wound of the intestine 
and out at the wound surface so as not to include the 
mucous membrane ; the needle is then passed through the 
wound surface on the opposite side, avoiding the mucous 
membrane, and brought out through the serous membrane 
a short distance from the edge of the wound. By this 
suture the lips of the wound are approximated. For 
additional security in preventing the escape of the contents 
of the intestine and to secure approximation of the serous 
surfaces a few Lembert sutures should be introduced. 

Joberfs Suture. 

This suture, which has been employed in transverse 
wounds of the intestine which completely or incompletely 

Fig. 187. 



Jobert's suture. 



divided the gut, is introduced after turning the lower end 
of the bowel in upon itself. When the division of the gut 



VARIETIES OF SUTURE. 



271 



was incomplete Jobert employed only one suture, when 
complete tw r o ; the ends of the sutures were brought out of 
the external wound. (Fig. 187.) By this method of suture 
the two serous surfaces are brought into contact. 

Sutures Employed in Intestinal Anastomosis. 

When it is desired to form a permanent orifice between 
two portions of the gut, the ends of the gut are closed and 

Fig. 188. 




Method of applying Senn's decalcified bone plates. (Geeig Smith 



an opening is made in each portion of the gut, and the walls 
of the gut surrounding the openings are held in contact 
with each other by sutures attached to perforated plates of 
decalcified bone ; this is the method devised by Senn. The 
manner of using the bone plates and sutures is shown in 
Figs. 188 and 189. To accomplish the same purpose 
rubber rings or perforated plates of rubber have been em- 



272 MINOR SURGERY. 

ployed, also rings made from catgut, to which the sutures 
are attached, are applied in the same manner as Sennas 
plates. In using the rubber rings or plates it is well to 
divide them at one or two points and unite them by catgut 
sutures which will soften and be dissolved in a few days 
and allow the ring or plate to change its shape and 
facilitate its passage through the bowels ; if catgut rings 
are employed these will be softened and dissolved in a 
short time so as to be passed without difficulty. 

Fig. 189. 




WALL OF 

INTESTINE 

TURNED IN AND 

SECURED BY , 

LEMBERT STITCHES 



Diagram showing position of bone plates in intestinal anastomosis after 
resection of the bowel. (Roberts.) 

At the present time many surgeons in performing in- 
testinal anastomosis dispense with the use of bone plates 
or rings and make use of Abbe's long incision, in which, 
after closing the two ends of the gut, the two portions are 
laid alongside of each other and two rows of continuous 
Lembert sutures are applied, a quarter of an inch apart 
and an inch longer than the proposed cut. The bowel is 
then opened for four inches a fourth of an inch from the 
sutures, both rows being to one side of the cut ; the op- 
posite portion of the bowel is then opened in the same 
manner, and the adjacent edges of the bowel are united by 
a continuous suture. The two free cut edges are then 
hemmed to secure any bleeding that may be present, after 
which the serous surfaces on the opposite sides of the 



VARIETIES OF SUTURE. 273 

opening are approximated and secured by two rows of 
continuous Lembert sutures. 

Intestinal anastomosis may be employed instead of 
Jobert's suture or the circular suture in wounds com- 
pletely dividing the intestine and after resection of the 
gut for the removal of growths or for stricture. 

Sutures Employed in Gastrostomy. 

In this operation, when the wall of the stomach has 
been exposed, two hare-lip pins should be thrust through 
the integument and tissues near the edge of the wound 
and then through the peritoneal and muscular coats of the 
stomach, to bring the surface of the stomach in contact 
with the peritoneum covering the inner surface of the 
abdominal walls in the region of the wound ; a few sutures 
of silk may also be introduced to secure the wall of the 
stomach to the edges of the wound. The opening of the 
stomach is postponed for four or five days if possible, 
until the adhesion between its walls and the abdominal 
parietes is secure, and at this time the sutures and the pins 
are removed. 

When immediate opening of the stomach is required for 
any reason, after the wall of the stomach has been exposed 
two silver-wire sutures are passed through the peritoneal 
and muscular coats of the viscus by means of a needle; 
these sutures should be placed transversely to the external 
abdominal wound and serve to draw the wall of the 
stomach in contact with the inner margins of the abdom- 
inal incision. 

A long silk suture is next passed through the outer 
coats of the stomach so that the loops project upon the 
external surface of the organ. A needle, having a hook 
near its extremity, is passed through the abdominal wall 
and engages the loop and draws it to the surface of the 
abdomen near the edge of the abdominal wound ; the same 
manipulation is repeated until all of the loops have been 
brought to the surface. (Fig. 190.) 

A piece of rubber tube is carried around the external 



274 



MINOR SURGERY. 



wound and slipped through the loops which project upon 
the surface of the abdomen, and by drawing the loops 
tight over the rubber tube and tying the ends of the suture 
the stomach wall is secured in contact with the inner mar- 
gins of the abdominal wound, and it may be safely opened 
after being thus fixed. 



Fig. 190. 




Sutures for immediate gastrostomy. (Roberts .) 

In the operation of gastrostomy, where the stomach has 
been exposed and opened and the foreign body removed, 
or its cavity has been explored, or its orifices dilated, as 
the case may be, the wound in the wall of the stomach is 
closed with Lembert's sutures, silk or catgut being the 
material employed for this purpose. The abdominal wound 
is next closed with deep sutures which include the parietal 
peritoneum. 



Ligatures Used in the Treatment of Vascular Growths. 

Various forms of ligature are used for the strangulation 
of vascular growths ; the material used for ligatures is 
usually strong silk or hemp thread, catgut, or silver wire. 



LIGATURES USED IN VASCULAR GROWTHS. 275 

The Single Ligature with a Pix. 

This is applied by first inserting a hare lip pin through 
the skin near the edge of the growth, passing it under the 
growth and bringing its point out through the skin at a 
point opposite the point of entry ; a strong silk or hemp 
ligature, which has been well waxed, is passed under the 
ends of the pin surrounding the base of the tumor and is 
drawn tight enough to strangulate the growth, and is 
secured by two knots (Fig. 191). If the growth is of 

Eig. 191. 




Vascular tumor strangulated with pin and ligature. (Roberts.) 

considerable size it is better before applying this ligature 
to introduce a second pin at right angles to the first one, 
and then secure the ligature under the pins. In applying 
these forms of ligatures to healthy skin the patient is 
saved much pain, and the separation of the mass is 
hastened, by cutting a groove in the skin with a sharp 
knife at the point where the ligature is to be applied ; the 
ligature when tied is buried in the groove thus made. 

Double Ligature in Vascular Growths. 

This ligature is applied by passing a needle or a needle 
with a handle, armed with a double ligature, through the 
skin near the growth, and then passing it under the tumor 
and bringing it out through the skin at a point directly 
opposite the point of insertion ; the ligature is then divided 
and the needle removed. The tumor is strangulated by 
tying firmly the corresponding ends of the ligature on each 
side of the tumor, each ligature including one-half of the 
growth (Fig. 192). 



276 



MINOR SURGERY. 



The double ligature may also be applied by first passing 
a pin under the growth and then passing a needle armed 



Fig. 192. 




Method of applying double ligature. (Roberts.) 

with a double thread under the tumor at right angles to 
the pin, and after removing the needle the ends of the 



Fig. 193. 




Method of applying double ligature and pin. (Bryant.) 

ligature are tied and the tumor is strangulated in two 
sections. (Fig. 193.) 

Quadruple Ligature. 

In applying this ligature two needles carrying a double 
thread are passed under the growth at right angles to 



LIGATURES USED IN VASCULAR GROWTHS. 277 

each other, or if the handled needles be used they may be 
first passed in this manner, and then threaded with double 
ligatures, which are carried under the growth as they are 

Fig. 194. 




Method of applying quadruple ligature. (Liston.) 

withdrawn. The needles being removed, the surgeon ties 
two ends of the ligature together,, and repeats this pro- 
cedure until the growth has been strangulated in four sec- 
tions. (Fig. 194.) 

Subcutaneous Ligature. 

This is applied by introducing a needle armed with a 
ligature through the skin near the growth, and carrying it 
through the subcutaneous tissues around the part to be con- 
stricted for a short distance, then bringing it out through 

13 



278 



MINOR SURGERY. 



the skin. The needle is again introduced through the same 
puncture, and is again brought out through the skin at 
some distance from the first point of exit. It is next intro- 
duced through this puncture and brought out at a more 
distant point. In this way the growth is completely en- 
circled by a subcutaneous ligature, which is finally brought 
out at the point of entrance ; the tumor is strangulated by 
firmly tying together the ends of the ligature. (Fig. 195.) 



Fig. 195. 




Method of applying subcutaneous ligature. (Holmes.) 

If a needle armed with a double ligature is first passed 
under the growth the ligature is divided, and by passing 
each end of the divided ligature subcutaneously around 
the growth it may be strangulated subcutaneously in two 
sections. 

Erichsen's Ligature. 

This ligature is employed to strangulate tumors of 
irregular shape in a number of sections. A strong silk 
or hemp ligature three yards in length, one-half of which 
is stained black, is carried by a needle as a double ligature 
under the growth at various points so as to leave a series 



ELASTIC LIGATURES. 



279 



of loops about nine inches long on each side of the tumor 
(Fig. 196); the black loops being cut on one side, the 



Fig. 196. 




Method of applying Erichsen's ligature. (Erichsex.) 
Fig. 197. 




Erichsen's ligature applied. 



white on the other, the ends are then firmly tied so as to 
strangulate the growth in sections. (Fig. 197.) 



Elastic Ligatures. 

Ligatures made of India-rubber varying from half a 
line to several lines in thickness are often made use of in 
surgery. They may be employed to strangulate growths 
such as moles or nsevi, or in the treatment of fistulse, and 



280 MINOR SURGERY. 

are especially useful in the treatment of those cases of 
fistula-in-ano in which the internal opening into the bowel 
is situated high up, as the division of such fistulse by this 
means is accomplished without hemorrhage and with less 
risk than by the employment of the knife. In applying 
elastic ligatures in such cases the ligature, after being 
passed through the fistula by means of a probe, is carried 
out through the internal opening ; the anus is next well 
stretched, and the elastic ligature is then firmly tied with 
two or three knots ; the greater the tension made before 
the ligature is tied the more rapidly will it cut its way out. 
The smaller sizes of rubber drainage-tubes may be sub- 
stituted for the solid rubber ligatures. 



Treatment of Hemorrhage. 

The surgeon may be called upon to treat the following 
varieties of hemorrhage : arterial, venous, or capillary ; and 
these again are classified according to the time of their 
occurrence, as primary, that is, bleeding which occurs at 
the time the wound is inflicted ; intermediary or consecutive, 
that which occurs within twenty-four or forty-eight hours 
after the reception of the injury, which generally takes 
place during the period of reaction ; and secondary, which 
takes place after forty-eight hours, and may occur at any 
time subsequent to this period until the wound is healed. 
The treatment of hemorrhage is either constitutional or 
local. 

The constitutional treatment of hemorrhage consists in 
keeping the patient in the recumbent posture and avoiding 
any sudden elevation of the head or arms which might 
induce fatal syncope. Opium is a valuable remedy and 
should be freely used. Ergot, gallic acid, acetate of lead, 
and tincture of iron may also be employed, and stimulants 
and food should be carefully administered, and in extreme 
cases auto-transfusion or the transfusion of blood or normal 
salt solution, as described on page 196 may be resorted to. 

In the local treatment of hemorrhage various measures 



CONTROL OF ARTERIAL HEMORRHAGE. 



281 



may be adopted which may be either temporary or perma- 
nent in their action. 



Temporary Control of Arterial Hemorrhage. 

This may be effected by pressure applied directly to the 
bleeding vessel in the wound or by pressure applied indi- 
rectly to the main artery between the point of its injury 
and the centre of the circulation, and this pressure may be 
made by the fingers, digital compression, by compresses, or 
by means of tourniquets. 



Digital Compression. 

This constitutes one of the most valuable means em- 
ployed in the temporary control of hemorrhage ; the finger 
is pressed directly upon the bleeding vessel, in the wound, 
or is used to make pressure upon the artery from which 

Fig. 198. 




Digital compression of the femoral artery. 

the bleeding arises at some point between the wound and 
the centre of the circulation. (Fig. 198.) Control of 
hemorrhage by digital pressure can only be mantained for 
a few minutes, for the fingers of the surgeon or assistant 



282 MINOR SURGERY. 

soon become tired, so that it is only employed until means 
are adopted for the permanent arrest of the bleeding. 
Digital compression of the radial and ulnar arteries is 
frequently resorted to for the control of hemorrhage dur- 
ing amputations of the fingers, also of the axillary and 
femoral arteries in amputations at the shoulder- and hip- 
joints. 

It is also used to control hemorrhage from wounds, 
either the result of accident or those made by the knife 
of the surgeon, in which case the finger is placed directly 
upon the divided vessel, or is employed to hold a sponge 
or compress firmly in the wound. 

Compresses. 

By the use of compresses placed directly in the wound 
or applied to the vessel between the wound and the centre 
of the circulation, the temporary control of hemorrhage 
may be very satisfactorily accomplished. Where it is pos- 
sible, the compress which is applied in the wound should 
be made of antiseptic or aseptic gauze, thereby diminish- 
ing the chances of wound-infection. 

The compress should be held in position by a bandage 
firmly applied, and is generally employed only as a tem- 
porary expedient until a more permanent means of con- 
trolling the bleeding is adopted. 

Tourniquets. 

These instruments, which are employed for the tempo- 
rary control of hemorrhage from wounds, are of many 
different kinds. 

Petit's tourniquet, which is the best for ordinary use, 
consists of two metal plates connected by a strong linen or 
silk strap, with a buckle — the distance between the plates 
being regulated by a screw. (Fig. 199.) In applying this 
tourniquet a compress or roller bandage is placed directly 
over the artery to be compressed and may be held in posi- 
tion by a few turns of the roller bandage. The lower plate 



CONTROL OF ARTERIAL HEMORRHAGE. 



283 



of the tourniquet is placed directly over this pad and the 
strap is tightly secured around the limb to keep the instru- 
ment in place. The screw is then turned so as to separate 
the plates and tighten the strap, thus forcing the compress 
or pad upon the artery and controlling its circulation. This 



Fig. 199. 




Petit' s tourniquet. 



instrument is very generally employed for the control of 
hemorrhage in wounds of the extremities, and is especially 
useful in amputation of these parts, being placed over the 
main artery some distance above the seat of operation. 



The Spanish Windlass. 

An improvised tourniquet, known as the Spanish 
windlass, may be employed in cases of emergency ; it is 
prepared by folding a handkerchief or piece of muslin 
into a cravat and placing a compress or smooth pebble on 
the body of the cravat ; this is placed over the artery to 



284 



MINOR SURGERY. 



Fig. 200. 



be controlled, and the ends of the handkerchief are tied 
loosely around the limb ; a short stick is passed through 

this loop, and by twisting the 
stick the loop is tightened and 
the compress is forced down upon 
the artery (Fig. 200). 

Many other forms of tourni- 
quet have been devised which 
have the pad and counter-pad 
arranged to make pressure upon 
the vessel desired, such as Lister's 
aorta compressor (Fig. 201 ), which 
is employed in the treatment of 
aneurism of the iliac vessels and 
for the control of hemorrhage 
in amputation at the hip-joint. 
Hoey's clamp (Fig. 202) and 
Signorini's tourniquet (Fig. 203) 
are constructed upon the same 
principle, and are frequently em- 
ployed to control the circulation 
in the femoral artery in cases of 
operations on the thigh and leg, 
and in the treatment of femoral 
or popliteal aneurism. 
The elastic tube, or strap of EsmarcNs apparatus (Fig. 
204) may also be employed for the temporary control of 
arterial hemorrhage, being applied above the wound, and 
if this is not at hand, any strong rubber cord, or a piece of 
large-sized drainage-tube may be used as a substitute. In 
hemorrhage from wounds of the hands and feet, especially 
in children, and in controlling hemorrhage from wounds 
of the penis, a piece of drainage-tube, firmly applied above 
the wound, may be employed with advantage. This tube 
or strap, although generally employed to control hemor- 
rhage from vessels of the extremities, may be used to 
control the femoral artery as it crosses the brim of the 
pelvis, by placing a compress over the artery in this posi- 
tion, and then applying the elastic band to secure it with 




The Spanish windlass. 



CONTROL OF ARTERIAL HEMORRHAGE. 



285 



a figure-of-eight turn, passing it under the thigh, crossing 
over the pad, and then carrying the ends around the 
pelvis, and securing them. 



Fig. 201. 




Lister's aorta compressor. 



Fig. 203. 



Fig. 202. 




Hoey's clamp. 




Signorini's tourniquet. 



To make pressure on the axillary artery, a compress 
should be placed in the axilla, and the middle of the tube 

13* 



286 MINOR SURGERY. 

placed over this to hold it in position ; the ends of the tube 
are then carried over the shoulder where they are crossed, 
and then carried to the opposite axilla and secured. 

Fig. 204. 




Elastic strap of Esmarch's apparatus. 

In amputation at the shoulder-joint, to make pressure 
upon the subclavian artery, which it is difficult to compress 
by an ordinary tourniquet, the handle of a large key well 
padded may be used ; it is firmly pressed against the vessel 
above the clavicle, and held by an assistant, and will prove 
a very satisfactory means of controlling the circulation in 
this vessel. 

Hcemostatie Forceps. 

The temporary control of arterial hemorrhage by the 
use of haemostatic forceps is now very generally employed 
in surgical operations, and their use has done much to 
diminish the shock following operations from the loss of 
blood. The haemostatic forceps in general use is self- 
retaining ; it is clamped upon the bleeding vessel, and is 
allowed to remain until the operation is completed, when 
the vessel is secured permanently by the application of a 
ligature, and the forceps is removed. The use of these 
forceps will be found very satisfactory in controlling 
hemorrhage during the removal of tumors, in cases of 
amputation, and for the temporary control of bleeding 
during the operation of tracheotomy they will be found 
most efficient, as also in abdominal operations, in which 
their utility was first demonstrated. (Fig. 205.) 



ESMARCWS BANDAGE AND TUBE. 



287 



Esmarch's Bandage and Tube. 

This apparatus, which is applied to the limbs to render 
them bloodless during operations, consists of a rubber 
bandage two and a half 
inches in width and three fig. 205. 

or four yards in length, and 
a rubber tube two yards in 
length, to one end of which 
is attached a chain and to 
the other a hook, or better 
a rubber strap, one inch in 
width and one and a half 
yards in length with a hook 
and chain. The bandage is 
applied to the extremity of 
the limb and is carried up 
the limb to a point some 
distance above the seat of 
proposed operation ; the 
bandage is applied firmly, 
each turn overlapping one- 
fourth of the preceding one, 
and when the last turn has 
been made the rubber tube 
or strap is wound firmly 
around the limb and secured 
by fastening the hook into 
one of the links of the 
chain. (Fig. 206.) After securing the tube or strap the 
rubber bandage is removed from the limb and if the tube 
has been firmly enough applied the limb will be found to 
be blanched, and should be free from blood during the 
operation. Care should be taken not to apply the tube or 
strap too tightly in poorly developed limbs, or on parts of 
the limb where large nerve trunks approach the surface, 
as they may be subjected to an amount of pressure which 
will interfere w T ith their functions subsequently. I have 
knowledge of one case of this nature in which permanent 




Haemostatic forceps. 



288 



MINOR SURGERY. 



paralysis of the limb followed the use of Esmarch's 
apparatus ; the tube should be applied with just enough 
firmness to control the circulation. 

As the strap, when firmly applied, completely cuts off 
the circulation of the parts below, it should be applied for 
as short a time as possible, as gangrene has resulted from 
its prolonged use. 

After the removal of the tube there is generally quite 
free capillary hemorrhage, due to paralysis of the vasomotor 
nerves from pressure, but this in a short time stops. This 

Fig. 206. 




Esmarch's bandage and tube applied. 

apparatus is of the greatest service in controlling hemor- 
rhage at the time of operation, and in amputations and 
removal of vascular tumors from the limbs will be found 
most satisfactory. In operations upon bone, either oste- 
otomy or sequestrotomy, it is especially useful, as it allows 
the surgeon to have a view of the parts unobscured by 
hemorrhage. I have found its use most satisfactory in 
operations for the removal of foreign bodies, such as 
needles imbedded in the hands or feet or extremities. 



Permanent Control of Arterial Hemorrhage. 



To secure this end the surgeon may resort to the use of. 
position, cold, heat, styptics, pressure, cauterization, liga- 
tion, torsion, or acupressure. 



CONTROL OF ARTERIAL HEMORRHAGE. 289 



Position. 

In arterial hemorrhage from wounds of the extremities 
elevation of the part will be found to materially diminish 
the amount of bleeding ; in hemorrhage from wounds of 
the arteries of the hand, forearm, foot, or leg, forcible 
flexion of the forearm on the arm or of the leg on the 
thigh will be found useful in diminishing the force of the 
blood-current. 

Gold. 

The application of cold by means of a stream of cold 
water or an ice-bag or pieces of ice will often be found an 
efficient means of controlling hemorrhage from vessels of 
small calibre ; it is especially applicable to hemorrhage 
from wounds of the vessels of the mouth, nostrils, vagina, 
or rectum. 

Hot Water. 

Hot water will be found a very efficient means of con- 
trolling hemorrhage from small vessels, and it may be 
used in the form of a hot antiseptic solution. It is of 
especial value in capillary or parenchymatous hemorrhage, 
and is employed in the form of a douche or by means of 
sponges dipped in the hot solution and packed into the 
wound. The injection of hot w T ater is a most satisfactory 
method of controlling uterine hemorrhage. 

Styptics. 

These agents are sometimes employed to control capil- 
lary bleeding or hemorrhage from small vessels, and 
although their use is often satisfactory as regards the 
control of the bleeding, they have the disadvantage of 
interfering with the primary union in wounds, and since 
the value of asepsis in wound treatment has been demon- 
strated they are now very seldom employed. The most 
valuable styptics which are used are alcohol, alum, oil of 



290 MINOR SURGERY. 

turpentine, perchloride of iron, and persulphate of iron or 
MonseFs solution, acetic acid, and vinegar. 

Pressure. 

For the permanent control of arterial hemorrhage 
pressure may be applied directly to the bleeding-point or 
surface by means of a compress of antiseptic gauze or by 
strips of gauze packed firmly into the cavity from whose 
surface the bleeding arises. 

Compresses are used with the best results where the 
proximity of a bone gives a firm substance upon which 
the vessel may be compressed, as is the case in the vessels 
of the scalp. Pressure applied by means of packing with 
strips of gauze will be found most efficient in controlling 
hemorrhage from cavities such as the nose, vagina, or 
rectum, and in the cavities resulting from the removal of 
necrosed or carious bone. Pressure may be indirectly 
applied by flexing the proximal joint over a compress or 
by firm bandaging of the limb. 

In controlling bleeding from a divided artery in a bony 
cavity, such as the inferior dental, a piece of catgut liga- 
ture may be forced into the canal, and will control the 
bleeding in a most satisfactory manner, or by forcing a 
small piece of Horsley's wax into the opening in the bone ; 
this wax is composed of wax, 7 parts]; oil, 2 parts ; and 
carbolic acid, 1 part. 

Halstead has introduced a material known as gut wool, 
which is prepared from the same material from which cat- 
gut is made. This is cut into fine shreds and is used to 
control hemorrhage from bone, being pressed into the open- 
ing or cavity in the bone from which the bleeding arises. 

The troublesome hemorrhage sometimes occurring after 
the removal of a tooth may be controlled by packing the 
alveolar cavity with a strip of iodoform gauze, or by 
introducing a wedge-shaped piece of cork and holding 
it in place by fastening the jaws together by means of a 
bandage. 



CONTROL OF ARTERIAL HEMORRHAGE. 



291 



Cauterization. 

The use of cauterization by means 
of a hot iron is a satisfactory method 
of arresting hemorrhage. Care should 
be taken to have the iron only of a 
dull-red or black heat, as the result 
desired is not the destruction of the 
tissues, but the coagulating effect of 
heat upon them. The form of cau- 
tery iron employed will depend upon 
the position of the vessel. Paque- 
lin's cautery is also a satisfactory 
apparatus to use for the control of 
hemorrhage. 

The control of arterial bleeding 
by cauterization is often resorted to 
in operations upon the jaws and in 
the removal of tumors from the 
mouth or pharynx or of the tonsils ; 
it is also frequently employed to con- 
trol hemorrhage in operations upon 
the uterus and the rectum, and also 
that resulting from the removal of 
abdominal tumors, where the appli- 
cation of a ligature is difficult and 
often impossible. 

Torsion. 

This method of controlling arte- 
rial hemorrhage consists in seizing 
the end of the artery, drawing it 
slightly out of its sheath and twist- 
ing it ; it may be accomplished with 
a single pair of forceps or by two 
pairs of forceps. In the latter method 
the vessel is held by one pair of 
forceps and is twisted by the second 
pair. 



Fig. 207. 



o o 



Hewson's torsion 
forceps. 



292 MINOR SURGERY 

Torsion of arteries in accidental wounds is quite com- 
mon, and in many cases controls the hemorrhage until 
surgical aid is rendered. I have seen the femoral artery 
in Scarpa's triangle completely controlled in this manner 
in a case of avulsion of the thigh from a railway injury. 

In vessels of moderate size it may be practised with one 
pair of forceps, and the ordinary double-spring artery for- 
ceps (Fig. 208) will be found satisfactory for such cases. 

Fig. 208. 




Double-spring artery forceps. 

In larger arteries two forceps should be employed, or some 
of the numerous forms of torsion forceps which have been 
devised for this purpose. (Fig. 207). 

Constriction or Crushing of Arteries for the Arrest of 
Hemorrhage. 

This procedure has been adopted for the closure of arte- 
ries without the use of ligatures or other foreign substance 
to be left in the wound. It was employed by the use of 
an instrument known as the artery constrictor, which 
grasped the artery and constricted it in such a way that 
the inner and middle coats were lacerated, but the external 
coat was preserved intact. 

Arteriversion. 

This method of controlling hemorrhage consists in con- 
stricting the mouths of the arteries divided in wounds and 
amputations by turning over the cut ends with a little 
instrument called an arteriverter ; with this instrument 
the ends of the divided artery may be retro verted, and the 
cut extremity of the artery is reinforced by the duplica- 
ture of its walls, thus surrounding its open mouth with 



CONTROL OF ARTERIAL HEMORRHAGE 



293 



such a quantity of arterial, muscular, and elastic fibres 
as to effectually close it. 

Ligation. 

The use of the ligature is by far the most generally em- 
ployed method of controlling arterial hemorrhage. The 
materials used for ligature are silk, hemp thread, catgut, 
horsehair, iron or silver wire. Catgut or silk is the mate- 
rial generally employed. The vessel is seized with a pair of 
artery or haemostatic forceps or a tenaculum (Fig. 209) and 

Fig. 209. 




Tenaculum. 



drawn out of its sheath, and a ligature of prepared catgut 
is thrown aronnd it and secured by a surgeon's knot, or 
by a reef knot and a surgeon's knot combined, and when 
firmly tied the ends of the ligature are cut short in the 
wound. Silk ligatures which have been rendered aseptic 



Fig. 210. 




Aneurism needle armed with ligature. 



are applied in the same manner, and the ends may be cut 
short in the wound. 

When ligatures are applied to vessels in their continuity 
they may be threaded into an eyed probe or aneurism 
needle (Fig. 210) and carried around the vessel and se- 



294 MINOR SURGERY. 

cured. A convenient method of applying a ligature to a 
bleeding- point in a deep wound, or to a vessel in tissues 
which are of such a nature as not to permit of the isola- 
tion of the vessel, is to use a curved needle threaded with 
a catgut ligature, which is passed deeply into the tissues 
near the vessel and brought oat on the opposite side ; the 
ligature thus placed is then firmly tied, and the ends are 
cut short in the wound. (Fig. 211.) 

Fig. 211. 




Artery occluded by suture. (Esmarch.) 

Acupressure. 

In this method of controlling arterial hemorrhage a 
needle or pin is used, which is thrust through the tissues 
in such a way as to compress the artery. There are a 
number of methods of using the needle or pin, and a few 
of these will be described. 



First Method of Acupressure. 

In this method the surgeon places a finger of his left 
hand upon the mouth of the bleeding vessel and with his 
right hand introduces the needle from the cutaneous sur- 
face and passes it through the thickness of the flap until its 
point projects for a couple of lines or so from the surface of 
the wound a little to the right side of the tube of the vessel. 
By forcibly inclining the head of the needle toward his 



CONTROL OF ARTERIAL HEMORRHAGE. 



295 



right he brings the projecting portion of its point firmly 
down on the side of the vessel, and after seeing that it oc- 
cludes the artery he makes it re-enter the flesh as near as 



Fig. 212. 



Fig. 213. 




Acupressure— first method ; raw 
surface. (Emchsen.) 




Acupressure— first method ; cutaneous 
surface. (Erichsen.) 



possible to the left side of the wound and pushes the needle 
through the flesh until its point comes out again at the cuta- 
neous surface. (Figs. 212 and 213.) 



Second Method of Acupressure. 

A straight needle threaded with a short piece of iron or 
silver wire, for the purpose of afterward retracting and 
removing it, is passed down through the soft parts a little 
to one side of the vessel ; its point is then raised up and 
passed over the artery and is then turned down again and 
thrust into the soft tissues on the other side of the vessel. 
(Fig. 214.) 

Third Method of Acupressure. 

In this method the point of the needle is passed into the 
tissues a few lines to one side of the vessel, then passed 
under it and afterward pushed on, so that the point again 
emerges a few lines beyond the vessel. A loop of wire is 
next passed over the point of the needle, and then after 
being carried over the vessel and passed around the oppo- 
site end of the needle it is drawn sufficiently tight to close 



296 



MINOR SUEGEEY. 



the vessel, and the ends of the wire are secured by making 
a twist around the stem of the needle. (Fig. 215.) 



Fig. 214. 



Fig. 215. 




Acupressure— second method. 
(Erichsen.) 



Acupressure— third method. 
(Erichsen.) 



Fourth Method of Acupressure. 

This method is identical with the third, except that a 
long pin is used in place of the needle, the head of the 
pin remaining outside the wound. 

Fifth Method of Acupressure. 

This method is identical with the third, except that a 
long pin is used in place of the needle, the head of the 
pin remaining outside the wound. 




Acupressre— fifth method. (Erichsen.) 



This method consists in passing a pin or needle through 
the soft tissues close to the artery, and by giving the pin 
a quarter or half rotation twisting the vessel upon itself, 



TREATMENT OF VENOUS HEMORRHAGE. 297 

and fixing the pin by thrusting its point deeply into the 
tissues beyond. (Fig. 216.) 

Sixth Method of Acupressure. 

This method consists in applying the pin as in the 
fourth method, but differs from it in crossing the ends of 
the wire behind the pin so as to embrace the mouth of the 
vessel between them. 

Seventh Method of Acupressure. 

This method consists in passing a long needle or pin 
through the cutaneous surface deeply into the soft parts at 
some distance from the vessel, making it emerge near the 
vessel, bridging over the artery and then thrusting it down 
into the soft parts on the other side of the vessel and 
making its point emerge again from the integument. 

Treatment of Venous Hemorrhage. 

Bleeding from small veins often stops spontaneously 
unless there is some pressure upon the wounded veins 
upon the cardiac side of the wound. It is, however, very 
satisfactorily controlled by position or by the application 
of a compress and bandage, or by the use of a ligature ; 
if the divided vein be a large one it is well to secure both 
ends by ligatures. The free bleeding arising from rup- 
tured varicose veins of the leg is easily controlled by the 
application of a compress and bandage, while hemorrhage 
from the larger veins, such as the jugular, should be con- 
trolled by the application of ligatures as in the case of 
wouuded arteries. The application of the lateral ligature 
to small wounds of veins of large size, such as the femoral, 
or to wounds of venous sinuses, has been recommended 
and employed with good results, this procedure consists 
in pinching up the wall of the vein so as to include the 
orifice of the wound and throwing a delicate ligature 
around it. 



298 MINOR SURGERY. 

The use of the actual cautery may also be required for 
the control of venous hemorrhage in positions in which 
its arrest by pressure or the ligature is not feasible. 

TREATMENT OF CAPILLARY HEMORRHAGE. 

Capillary or parenchymatous hemorrhage is usually 
arrested spontaneously by the exposure of the injured 
surface of the wound to the air, but it is often so profuse 
that its arrest becomes a matter of importance. To con- 
trol this form of bleeding, pressure may be applied to the 
bleeding surface for a short time, and if this fails to arrest 
it, sponging the surface with dilute alcohol will sometimes 
prove satisfactory ; but the best application to arrest hem- 
orrhage of this nature is hot water, which may be used in 
the form of a hot bichloride solution. Acetic acid and 
vinegar are also sometimes employed for the same purpose. 
In cases where the means mentioned above fail to control 
the bleeding, it may be necessary to pack the wound with 
strips of antiseptic gauze ; this dressing is most service- 
able when the hemorrhage comes from cavities such as 
result from the removal of tumors or excisions of joints, 
and for the control of bleeding following the removal of 
necrosed or carious bone. To control hemorrhage from 
the mucous cavities, such as the nose, rectum, and vagina, 
this method of treatment is frequently resorted to. 

Treatment of Secondary Hemorrhage. 

Secondary hemorrhage following the use of the ligature 
or other means of controlling bleeding is, since the adop- 
tion of the antiseptic method of wound-treatment, a much 
less frequent complication of wounds. The treatment of 
this complication is both constitutional and local ; the con- 
stitutional treatment consists in the use of those remedies 
which were mentioned as serviceable in primary hemor- 
rhage, and the drugs upon which the most reliance is to 
be placed are opium and ergot. 



TREATMENT OF SECONDARY HEMORRHAGE. 299 

The local treatment of this form of hemorrhage consists 
in the use of the various means of controlling hemorrhage 
which have been mentioned before, such as the ligature, 
hot water, pressure, or the actual cautery. If possible, it 
is well to secure the vessel from which the bleeding arises 
in the wound ; if for any reason this cannot be done, the 
main artery should be ligated above the wound if the 
hemorrhage be arterial. 

Rules for Ligating Wounded Arteries, 

The following rules for the application of ligatures to 
wounded arteries are laid down by Ashhurst : 

1. In cases of primary hemorrhage, no operation should 
be performed upon an artery, unless it is at the moment 
actually bleeding. The exception to this rule is in the 
cases where the vessel is seen to pulsate in the wound or 
where the wound involves the region of a large artery and 
the patient has to be transported or may be in such a posi- 
tion that it will be impossible to receive surgical aid sub- 
sequently if needed ; under these circumstances, the vessel 
should be tied or the wound should be explored to ascer- 
tain the fact that no important vessel has been injured. 

2. In applying a ligature to a wounded artery, the sur- 
geon should cut down directly upon it at the point from 
which it bleeds and secure it in the wound. 

This rule holds good for both primary and secondary 
hemorrhage. 

3. Two ligatures should be applied, one to each end of 
the artery if it be completely divided, and one on each 
side of the wound if the latter has not completely severed 
the coats of the artery. This procedure is adopted for the 
reason that the arterial anastomosis is so free that the 
proximal ligature will not always, even temporarily, arrest 
the bleeding ; and if it does accomplish this object at the 
time, after the collateral circulation is established, bleeding 
is apt to occur from the distal extremity of the divided 
vessel. If the coats of the artery are not completely sev- 
ered their division should be completed, either before or 



300 MINOR SURGERY. 

after the application of the proximal and distal ligatures, 
thereby favoring the contraction and retraction of the 
ends of the divided vessel. 



Control of Hemorrhage from Special Parts. 

Epistaxis or hemorrhage from the nose may be so pro- 
fuse as to require surgical interference. To control this 
form of hemorrhage the application of iced compresses to 
the surface of the nose may first be made use of, and if 
this fails to control the bleeding, the surgeon or the patient 
should grasp the cartilaginous portion of the nose with his 
thumb and forefinger in such a manner as to keep the nos- 
trils tightly closed, which will prevent the passage of air 
through the nose and thus permit clots to form, arresting 
the flow of blood. Bleeding from the nose often arises 
from the erosion of a small artery low down upon the 
septum ; it can be freely exposed by introducing a nasal 
speculum, and the bleeding point can be touched with a 
cautery iron, avoiding the necessity of plugging the nares. 
If these simple means fail to arrest the bleeding the nasal 
cavity or cavities may be packed with strips of antiseptic 
gauze introduced into the anterior nares, and pushed back- 
ward by a director or probe; this will often be found a 
perfectly satisfactory means of arresting the bleeding. 
This method may be supplemented by a plug of antiseptic 
cotton introduced into the posterior nares with the fingers. 
The use of a rubber tampon, consisting of a rubber bag, 
introduced into the nares in an empty state and afterward 
inflated, has also been recommended for the control of this 
variety of hemorrhage. 

Another method of controlling hemorrhage from the 
nose consists in introducing a small piece of sponge, tied 
to a strong silk ligature, into the anterior nares and push- 
ing it back along the floor of the nose to the posterior 
nares ; a small piece of sponge about the size of a marble 
with a hole in the centre is threaded on the ligature and 
pushed back until it comes in contact with the first piece 



HEMORRHAGE FROM SPECIAL PARTS. 



301 



of sponge introduced, and thus by introducing a number 
of pieces of sponge in this way the nasal cavity may 
be completely filled up and the bleeding arrested. Care 
should be taken to see that the sponge has been rendered 
aseptic before being introduced, and the nasal cavity should 
also be washed out with an antiseptic solution before its 
introduction. The sponges may be allowed to remain in 
place for twenty-four to forty-eight hours. (Fig. 217.) 



Fig. 217. 




Plugging the nares from the front. (Roberts.) 

Plugging the nares by means of Bellocq's canula is also 
employed to arrest hemorrhage from the nasal cavities; the 
canula, armed with a strong ligature, is passed along the 
floor of the nose until it reaches the pharynx, when the 
spring being protruded, the ligature is seized and brought 
out of the mouth and secured to a plug of lint or antiseptic 
gauze of the required size, and upon withdrawing the in- 
strument the plug is brought into position in the posterior 

14 



302 



MINOR SURGERY. 



Dares and the end of the ligature is allowed to protrude 
from the mouth to facilitate its removal. (Fig. 218.) An 
ordinary flexible catheter may be employed in place of 
Bellocq's canula for the introduction of the ligature. 



Fig. 218. 




Plugging the nares with Bellocq's canula. (Fergusson.) 



Hemorrhage from the Urethra. 

In hemorrhage from the urethra, if profuse, the blood 
will trickle from the meatus, or if efforts at micturition 
are made the first gush of urine will contain blood, but 
afterward will be clear, and the last urine will contain a 
few drops of pure blood. 

This variety of bleeding, if it proceeds from the anterior 
portion of the urethra, may be controlled by the introduc- 
tion of a catheter and the application of a bandage around 
the penis, carefully applied so as to make only moderate 
pressure. 

If the bleeding comes from the posterior portion of the 
urethra, it will often be controlled by the application of 
cold or pressure to the perineum, or by the introduction of 



HEMORRHAGE FROM SPECIAL PARTS. 303 

a cold steel bougie, or by the injection of a solution of 
tannic acid. 

Hemorrhage from the Bladder. 

In this variety of hemorrhage the first portion of the 
urine may be blood-stained and the last portion will con- 
tain more blood and clots as the organ contracts, which 
distinguishes it from hemorrhage from the kidneys, in 
which the admixture of blood with the urine renders it of 
a smoky color or dark-red if the bleeding is profuse. 

To control bleeding from the bladder a catheter should 
be introduced and the urine and clots withdrawn ; the 
bladder should next be washed out with a warm or cold 
boric acid solution. In severe cases weak astringent 
solutions, such as tannic acid or alum, may be employed. 
The application of ice to the perineum and supra-pubic 
regions may also be employed with advantage. 

Hemorrhage from the Rectum. 

This variety of bleeding may be controlled by the in- 
jection of cold or astringent enemata. If the bleeding be 
profuse a speculum should be introduced, and when the 
source of the bleeding has been discovered the actual cau- 
tery or a ligature should be applied. If this is not feasible 
the rectum may be plugged with strips of antiseptic gauze, 
or a piece of a rubber catheter of large calibre may be 
wrapped with gauze and introduced into the rectum, the 
end of the catheter being allowed to protrude; by using 
this tube flatus can escape, and if the bleeding is not con- 
trolled blood will escape through the tube, preventing the 
risk of concealed hemorrhage. If the bleeding arises from 
hemorrhoids or polypus of the rectum the operative treat- 
ment of these conditions should be undertaken to perma- 
nently control the bleeding. 



304 MINOR SURGERY. 



Opening and Dressing of Abscesses. 

In operations for the evacuation of the contents of ab- 
scesses, care should be taken to observe every precaution 
to prevent a new infection of the wound or abscess cavity; 
the skin over the abscess should be carefully cleaned to 
make it aseptic, the hands of the surgeon and the instru- 
ments to be brought in contact with it should also be 
aseptic. These precautions should be especially observed 
in the opening of chronic abscesses when a new variety of 
infection is liable to be set up if aseptic precautions are 
not rigidly observed. 

Acute abscesses, as a rule, should be opened by incision, 
and this is best done with a straight, narrow, sharp-pointed 
bistoury ; the incision should be deep enough to freely 
expose the cavity of the abscess, and should be so planned 
as to be parallel with and not across important structures, 
and it should also be made at as dependent a portion as 
possible. Abscesses of the limbs are opened by a longi- 
tudinal incision, and those in the region of the anus and 
breast by an incision radiating from the anus or nipple. 

In deep-seated abscesses in the region of important 
structures the method of opening suggested by Mr. Hilton 
may be employed with advantage ; it consists in making 
a small incision through the skin and cellular tissue ; a 
director is next pushed through the tissues into the abscess 
cavity, which will be shown to have been reached by the 
escape of a little pus along the director; a dressing forceps 
with the blades closed is now pushed along the director 
into the abscess cavity, and when this has been accom- 
plished the director is withdrawn and the forceps is re- 
moved with the blades expanded so as to dilate the wound 
and allow the pus to escape. 

The cavity of the abscess having been emptied of pus, it 
should be irrigated with a stream of carbolic acid solution 
1 : 40, or bichloride solution, and if the cavity is not very 
large or deep no drainage-tube need be introduced, and a 
small piece of protective may be placed between the lips of 



OPENING AND DRESSING OF ABSCESSES. 305 

the wound to prevent their adhesion ; but if, on the other 
hand, the cavity is extensive and deeply situated, a rubber 
drainage-tube or a strip of iodoform gauze should be 
introduced to the bottom of the cavity to secure free 
drainage, and fixed at the surface of the skin by a safety- 
pin. A piece of protective which has been dipped in 
bichloride solution is next placed over the wound, and 
over this is laid a gauze dressing, consisting of a number 
of layers, which has been moistened in carbolic or bi- 
chloride solution ; this is covered by a number of layers 
of dry gauze which is in turn covered by a piece of rubber 
tissue. The latter may be omitted, and over this is placed 
a few layers of bichloride cotton, and the dressing is finally 
secured by a roller bandage. The dressing is removed at 
the end of two or three days, the cavity being washed out 
with one of the antiseptic solutions previously mentioned. 
The drainage-tube may then be shortened or removed, and 
the dressings reapplied as at the primary dressing. Under 
this method of treatment acute abscesses usually heal more 
promptly and with less suppuration than under the older 
methods of treatment in which poultices were applied. 

Chronic or tuberculous abscesses, which occur chiefly in 
connection with diseases of the bones or joints or of the 
lymphatic system, and are generally tubercular in their 
origin, may be opened in various ways, the time at which 
this should be done depending upon the size and situation 
of the abscesses and the amount of constitutional and 
local disturbance which the patients experience from their 
presence. 

A tuberculous abscess may be evacuated by means of the 
aspirator ; the pus being withdrawn as far as possible, the 
puncture is sealed with a small piece of gauze covered 
with iodoform collodion. Reaccumulation of the pus 
often takes place, and the aspiration has to be repeated a 
number of times. The greatest difficulty in the successful 
removal of the contents of cold abscesses by means of 
aspiration is the presence of masses of lymph in the pus 
which occlude the canula and often prevent the complete 
emptying of the cavity. 



306 MINOR SURGERY. 

These abscesses may also be evacuated by making a 
puncture through the skin and overlying tissues with a 
narrow bistoury, the surface having been previously thor- 
oughly w r ashed with soap and water and with a carbolic 
or bichloride solution ; a director is next pushed through 
this small wound into the cavity of the abscess, and the 
pus is allowed to escape by stretching the wound by the 
director ; when the cavity is emptied of pus it is washed 
out with a carbolic or bichloride solution introduced into 
it by pushing the nozzle of a syringe into the cavity, and 
this is allowed to escape in the same way as the pus 
previously did. When the irrigating solution has all 
escaped the cavity may be injected with an emulsion com- 
posed of iodoform one part, glycerin ten parts ; after this 
has been introduced the small wound is closed by a com- 
press of antiseptic gauze held in place by a compress of 
bichloride cotton and a bandage or by strips of adhesive 
plaster. The injection of the iodoform emulsion need not be 
repeated as long as iodoform continues to be excreted with 
the urine. Tuberculous abscesses are also treated by making 
a free incision into the abscess cavity with full antiseptic 
precautions, and after the escape of the purulent matter 
the walls of the abscess should be thoroughly scraped with 
a curette, and after the cavity has been freely washed out 
with a carbolic or bichloride solution large drainage-tubes 
are introduced and an antiseptic dressing is applied to the 
wound. The dressings are removed as soon as they become 
soaked, aud the drainage-tubes are shortened or removed 
as the discharge diminishes and the cavity contracts. 

In evacuating tuberculous abscesses by means of the 
aspirator or by a small puncture, there is absence of shock, 
and the loss of blood is insignificant, so that these pro- 
cedures should generally be first employed, and the more 
radical operation of incision and curetting of the cavity 
of the abscess, which is accompanied with a certain amount 
of shock and hemorrhage, should be reserved for those 
cases in which the less severe operations have failed to be 
followed by a satisfactory result. 

Diffused suppuration is treated by numerous punctures 



DRESSING OF WOUNDS. 307 

or incisions, which allow the purulent matter to escape, 
and where sloughs are present free incisions may be re- 
quired to give exit to the necrosed tissues ; the introduc- 
tion of drainage tubes may also be required. The wounds 
and the cavities, as far as possible, should be washed out 
with a carbolic or bichloride solution, and an antiseptic 
gauze dressing should be applied. 

Sinuses resulting from abscesses, if superficial, should 
be laid open freely and their surfaces should be scraped 
with a curette, and they should then be lightly packed 
with strips of bichloride or iodoform gauze and should be 
covered by an antiseptic dressing. If they are too deep 
to be treated by incision their healing may be facilitated 
by the injection of stimulating solutions introduced by 
means of a syringe ; the employment of solutions of 
chloride of zinc, nitrate of silver, and sulphate of copper 
varying in strength from five to twenty grains to the 
ounce of water will often prove satisfactory. 

Dressing of Wounds. 

Incised wounds present the conditions favorable for 
prompt healing, and they should first be carefully irrigated 
wdth an antiseptic solution to remove any blood-clots or 
foreign bodies, and after any hemorrhage which is present 
is controlled by the use of ligatures, if the wound be an 
extensive or deep one, provision should be made for drain- 
age by introducing a drainage-tube or a few strands of 
sterilized catgut at the bottom of the wound, allowing the 
extremity to project from the most dependent portion of 
the wound. In superficial incised wounds, after the hem- 
orrhage has been controlled, it is not usually found neces- 
sary to make any provision for drainage. If the wound 
be a deep one, involving the muscles and deep fascia, 
buried sutures of catgut should be applied to approximate 
the muscles and fascia, and if important nerves or tendons 
have been divided their ends should be brought into appo- 
sition by sutures of catgut or sterilized silk ; the superficial 
portions of the wound should next be brought together by 



308 MINOR SURGERY. 

the introd action of a number of interrupted sutures, catgut, 
silkworm-gut, silver wire or silk being employed for this 
purpose ; the accurate apposition of the edges of wounds 
of this variety is secured by the introduction of a number 
of sutures placed closely together. 

After a wound of this variety has been closed the sub- 
sequent dressing is accomplished by dusting the surface of 
the wound with iodoform or aristol, and a piece of pro- 
tective a little larger than the wound, which has been 
dipped in a 1 : 40 carbolic solution, is placed over it ; over 
this is placed a pad of antiseptic gauze, composed of ten 
or twelve layers, which has been soaked in a 1 : 40 carbolic 
solution or a 1 : 2000 bichloride solution, and over this is 
laid a pad of dry antiseptic gauze of the same thickness, 
overlapping the wet gauze by a few inches in all directions ; 
a few layers of bichloride cotton are next applied over the 
gauze dressings and the whole dressing is secured in posi- 
tion by the application of an antiseptic gauze bandage. 
Under this form of dressing prompt healing of incised 
wounds is the rule, and the wound need not be re-dressed 
for a week or ten days unless some indications exist for 
the change of dressing at an earlier period. Dry or moist 
sterilized dressings may also be employed. At the time 
of the first dressing the catgut drain or the drainage-tube 
is usually removed, and if the adhesion of the edges of 
the wound is firm the sutures may also be removed. An 
antiseptic dressing is usually next applied and allowed to 
remain in position for a few days longer. 

Lacerated wounds present edges which are torn and not 
sharply cut, and the vitality of the injured parts is often 
so seriously impaired that prompt union in this variety of 
wounds is not, as a rule, to be looked for. Wounds of this 
nature should first be irrigated with an antiseptic solution, 
as in the case of incised wounds, and blood-clots and for- 
eign bodies should be removed. If the wounds be deep, 
drainage-tubes should be introduced ; on the other hand, 
if they be superficial, or if the edges are not closely ap- 
proximated, provision for drainage may be omitted. The 
torn or irregular edges of the wound should next be 



DBESSIXG OF WOUNDS. 309 

brought into apposition at a few points, by the introduc- 
tion of catgut or silkworm-gut sutures, applied not very 
closely together ; and if the edges are discolored and their 
vitality seems markedly impaired, it is better not to use 
sutures, but rest satisfied by bringing them as nearly as 
possible in contact by the use of a few strips of isinglass 
plaster moistened with a bichloride solution. If the edges 
of the wound are so much crushed as to have their vitality 
destroyed, they may be trimmed away with scissors until 
a surface possessing fair vitality is secured. The evil 
results arising from the introduction of sutures into this 
variety of wounds, with the idea of closely approximating 
their edges, are so common that the surgeon who dispenses 
with the use of sutures entirely errs upon the safe side. 
The use of many sutures in wounds of this nature often 
causes marked tension in the wound, which is frequently 
followed by impairment of the vitality of the injured tis- 
sues, and sloughing results. 

The wound should next be dressed antiseptically, and if 
it runs a favorable course it need not be re-dressed for a 
week or ten days ; the time required for the repair of a 
wound of this nature is longer than that for an incised 
wound, and more frequent dressing may be required. 

In lacerated wounds of the extremities continuous irri- 
gation of the wound by a warm bichloride or carbolic' 
solution, applied as described (page 174), is often followed 
by the most satisfactory results ; wounds produced by 
machinery and railway accidents, in which the vitality of 
the tissues is much impaired, are particularly favorable 
cases for this method of treatment, and here the same caution 
should be exercised as regards the introduction of sutures. 

Contused Wounds. — This variety of wounds possesses 
many characteristics in common with lacerated wounds ; 
the edges are bruised and the injury of the subcutaneous 
tissue is often more extensive than the size of the external 
wound would lead one to suspect. They are dressed in 
the same manner as lacerated wounds, and the same objec- 
tion here exists to the use of sutures as in the latter class 
of injuries. 

14* 



310 MINOR SURGERY. 

Punctured Wounds. — These wounds are inflicted by 
sharp-pointed instruments, and it often happens that a 
portion of the vulnerating body remains in the wound, as 
is frequently the case in wounds produced by needles ; and 
another complication in this variety of wound is the injury 
of vessels, giving rise to concealed hemorrhage, or of nerves, 
resulting in neuritis. Simple punctured wounds should be 
carefully washed with an antiseptic solution and covered 
by an antiseptic gauze dressing, and if no complication 
exists their healing is usually very rapid. 

When, however, a foreign body remains in the wound, 
as it often happens in punctured wounds produced by 
needles and pins, the punctured wound should be con- 
verted into an incised wound, and the body should be 
searched for and removed if possible, and in doing this in 
the case of wounds of the extremities the operation is much 
facilitated by the employment of Esmarch's bandage and 
strap. After the removal of the foreign body the wound 
is treated as an incised wound, and an antiseptic dressing 
should be applied. When concealed hemorrhage occurs 
after a punctuted wound, the wound should be laid open 
and the bleeding vessel searched for and ligatured if possi- 
ble, and the wound should afterward be dressed as an 
incised wound. 

Poisoned Wounds. — These wounds are caused by the 
absorption, by means of a cut or abrasion in the skin, of 
fluids from a dead body in making dissections or post- 
mortem examinations or in operating upon living subjects, 
and often result in serious consequences. Such wounds, 
as soon as possible after their reception, should be care- 
fully washed out with a solution of bichloride of mercury, 
1 : 2000, or a 30-grain solution of chloride of zinc, and 
then dressed with an antiseptic dressing. If, however, this 
precaution is not taken or the wound has escaped notice, 
and in a few hours becomes inflamed and painful, and 
evidences of lymphatic involvement show themselves, 
the wound should be opened and its surface should be 
thoroughly washed out with a 30-grain solution of chlo- 
ride of zinc, and finally with a 1 : 2000 bichloride solution, 



DRESSING OF WOUNDS. 311 

and it should then be dressed with an antiseptic gauze 
dressing. Under this method of dressing the poisoned 
wound is often converted into a healthy one, even after 
the lymphatic involvement is well marked, and it usually 
heals promptly without further constitutional disturbance. 

Gunshot Wounds. — These wounds are produced by small 
shot, balls, or fragments of shells, and are of the nature of 
contused and lacerated wounds, and the vulnerating body 
as well as portions of the clothing are often imbedded in 
the tissues. 

In dressing these wounds any foreign bodies, if they can 
be located, should be removed, and in the search for and 
removal of balls from the extremities the application of 
the Esmarch bandage and strap will be found most useful. 
The wound should next be thoroughly washed out with a 
1 : 2000 bichloride solution, and an antiseptic dressing ap- 
plied as in the case of other contused and lacerated wounds. 

Powder burns resulting from the explosion of powder, 
in addition to the burning and laceration of the tissues, 
are accompanied by the introduction of grains of unburnt 
powder into the skin, which, if not removed, leave perma- 
nent points of pigmentation. These wounds should first 
be washed with an antiseptic solution, and upon the face, 
to avoid unsightly pigmentation of the skin, care should 
be taken to pick out the small masses of powder with a 
needle or the sharp point of a tenotomy knife. The sur- 
face should then be dressed with antiseptic gauze or with 
lint spread with an ointment of boric acid or an ointment 
of aristol, consisting of half a drachm or a drachm of 
aristol to an ounce of vaseline, this dressing being covered 
by a few layers of bichloride or borated cotton, held in 
place by a roller bandage. 

Contusions or bruises differ from contused wounds in the 
fact that the skin is not broken, though in spite of this 
fact there may exist very extensive laceration of the sub- 
cutaneous tissues, accompanied by more or less extravasa- 
tion of blood from the injured vessel. When not severe 
enough to require operative treatment they should be 
dresssed by applying over them several layers of lint satu- 



312 MINOR SURGERY. 

rated with lead-water and laudanum, and over this dress- 
ing is placed a layer of waxed paper or rubber tissue, and 
the dressing is secured by a roller bandage. 

Brush-barn. — This is a form of contused wound which 
is produced by violent friction applied to the surface of 
the body, and is often produced by coming in contact with 
rapidly revolving wheels or the belting of machinery, or 
by the body being rapidly propelled over an uneven sur- 
face, or by a rope being rapidly drawn through the closed 
hands. The injury may vary from a superficial abrasion to 
the absolute destruction of the skin. The surface of the 
brush-burn should be cleansed by a stream of sterilized 
water or 1 : 2000 bichloride solution, and should then be 
dressed with a powder of iodoform and boric acid, equal 
parts, and a sterilized gauze dressing should be applied ; 
if suppuration occurs, a dressing of boric ointment should 
be applied. 

A solution which I find most satisfactory in the dress- 
ing of contusions is as follows : 

Ammonii chloridi grs. xx. 

ScotJns} -ch . . m- 

Aquae q. s. ad fsj. 

Several layers of lint saturated with this solution are 
laid over the contused tissues, and are covered with waxed 
paper, oiled silk, or rubber tissue. 

Extensive collections of blood following contusions often 
remain in the tissues for some time, but usually are ab- 
sorbed. If this result does not follow, or an abscess forms, 
the blood or pus should be removed by aspiration or by 
incision with full antiseptic precautions. 

Burns and Scalds. 

The dressings employed in the treatment of burns and 
scalds are similar, as the injury to the tissues is practically 
the same in both classes of injuries. Superficial burns or 
scalds, in which the effect of the heat has only extended 
to the superficial layer of the skin, may be treated by the 



BURNS AND SCALDS. 313 

application of lint saturated with a solution of carbonate 
of sodium, a drachm to an ounce of water ; this dressing 
rapidly relieves the pain, and is a satisfactory application 
in this variety of burns and scalds. In cases in which 
the effects of heat have extended to the deeper tissues, the 
affected surface may be dressed with carron oil, which is 
prepared by rubbing together lime-water and linseed oil 
until a thick creamy paste results ; lint is saturated with 
this mixture and laid over the surface of the burn or scald. 
The dressing is a comfortable one to the patient, but soon 
becomes offensive, and for this reason requires frequent 
renewal. 

The disadvantage met with in the antiseptic method of 
dressing burns and scalds is the fact that the raw surface 
presented offers the most favorable conditions for the ab- 
sorption of the antiseptic substances employed in the dress- 
ings, and for this reason the use of bichloride of mercury, 
carbolic acid, and iodoform is not to be recommended in 
burns or scalds involving a large extent of surface, on 
account of the toxic symptoms which may result from their 
employment. 

A recent burn or scald, by reason of the heat employed 
in its production, is practically an aseptic wound, and it 
may be dressed by covering it with a number of layers of 
sterilized gauze and cotton, and with boric acid ointment, 
and placing over this a number of layers of borated or 
salicylated cotton, and holding the dressings in position 
by a bandage. 

If, however, a full antiseptic dressing is employed, the 
injured surface should first be irrigated with a 1 :60 car- 
bolic or 1 : 4000 bichloride solution, and then covered with 
protective or rubber tissue which has been sterilized, and 
over this a dressing of carbolized or bichloride gauze and 
bichloride cotton should be applied. 

Aristol, as a substitute for iodoform, may be employed 
in the dressing of burns or scalds, being either dusted 
over the surface or used in the form of an ointment, and 
over this application should be placed a few layers of 
borated or salicylated cotton. 



314 MINOR SURGERY. 

When blebs are present upon the surface of the burn or 
scald, they should be opened to allow the serum to escape. 
If suppuration occurs, or the tissues become necrosed by 
reason of the severity of the injury, the surface of the burn 
may be washed with a 1:60 carbolic solution or 1 : 4000 
bichloride solution, and the same dressing should then be 
applied. 

The ulcers resulting from the separation of the dead 
tissues should be touched with a solution of nitrate of 
silver, four grains to the ounce of water, and dressed with 
lint spread with an ointment of boric acid or aristol. In 
the dressing of extensive burns or scalds of the neck, face, 
and region of the joints, the possibility of serious deformity 
from contraction of the tissues in healing should not be 
lost sight of, and position, splints, and bandages should be 
employed to prevent, as far as possible, this complication. 

Bedsores. 

These sores usually occur over the sacrum or hips in 
patients who are confined to bed for a considerable time, 
as the result of a long-continued pressure, or in those cases 
where the vital powers are depressed by adynamic diseases, 
and are also a frequent and troublesome complication in 
spinal injuries, in which cases they result from trophic 
disturbances. Their formation may be prevented in 
many cases by the use of air-cushions or of a water mat- 
tress and by keeping the parts exposed to pressure scrupu- 
lously clean and frequently bathing them with stimulating 
lotions, such as alcohol, olive oil and alcohol equal parts, 
or soap liniment. The parts should also be protected from 
pressure by the application of adhesive plaster, or, still 
better, soap plaster spread upon chamois. When a bed- 
sore has actually formed, and in many cases its formation 
is very rapid and the slough will be found to involve a 
large surface of the skin over the sacrum, and to extend 
down to the bone, we have present a very serious compli- 
cation, and one which requires most careful treatment. 



SPRAINS. 315 

The dressing of a bedsore before the separation of the 
slough consists in relieving the part from pressure by the 
use of an air cushion placed under the buttocks, and the 
application of a fermenting poultice until the slough has 
separated. When the slough has become detached the 
ulcer remaining should be well washed with a carbolic or 
bichloride solution, and the granulations should be touched 
with a 5-grain solution of nitrate of silver; and resin 
cerate, iodoform, aristol, or boric acid ointment, spread 
upon lint, should be applied to the surface of the ulcer, 
and a piece of soap plaster a little larger than the ulcer 
should be placed over this dressing and held in place by 
broad strips of adhesive plaster. This dressing should be 
renewed every day or every other day, and means should 
be adopted to protect the parts from further pressure, and 
the constitutional condition of the patient should be im- 
proved by the administration of a nutritious diet, tonics, 
and stimulants. The application of the galvanic current 
has been employed with good results to promote the heal- 
ing of the ulcer in obstinate cases. 



Sprains. 

Sprains of joints from twists or other external violence 
resulting in the stretching or laceration of the ligaments 
are injuries which require careful dressing. 

Sprains may be first treated by the application of cold- 
or hot-water dressings for a few hours, or by the applica- 
tion of lead-water and laudanum, the joint being kept at 
rest by the use of a splint or by confining the patient in 
the recumbent posture in the case of sprains of the joints 
of the lower extremities. 

After a few days' use of the lead-water and laudanum 
dressing the swelling usually subsides and the joint may 
be fixed by the application of a moulded soap-plaster splint 
or felt splint held in place by a firmly applied roller ban- 
dage, which should be worn for a week or ten days ; in 
ordinary cases after this time the splint may be removed 



316 MINOR SURGERY. 

and the patient should be encouraged to use the joint. In 
cases of severe sprains, on the other hand, the pain and 
swelling persist for some time, and here the fixation of 
the joint by a soap plaster, or better by a plaster-of-Paris 
bandage, will be found useful for a few weeks. If upon 
the removal of this dressing the parts are still painful 
and swollen, the swollen tissues should be painted with 
tincture of iodine ; or the method of applying tincture of 
iodine recommended by Mr. Jordan, that is, the applica- 
tion of the iodine in a broad band around and not over 
the swollen tissues, may be employed. The joint should 
next be surrounded by a piece of lint spread with an 
ointment composed of equal parts of ointment of mercury 
and ointment of belladonna, and a moulded soap-plaster 
splint being fitted to the joint, it is held in place by a 
firmly applied bandage. This will be found a most satis- 
factory dressing in the treatment of sprains after they 
have passed their acute stage. The dressing is removed 
at intervals of three or four days, the joint is sponged off 
with alcohol, and a similar dressing is reapplied ; and this 
method of dressing may have to be continued for some 
weeks, but the results obtained by its continuous use are 
often most satisfactory. An ointment of ichthyol one part 
to lanolin three parts may also be used in the same manner 
as the ointment of belladonna and mercury with good re- 
sults in the treatment of these injuries. 

The treatment of sprains which I have found the most 
satisfactory, both in the acute and chronic stage, consists 
in the use of strapping. Strips of rubber adhesive or ad- 
hesive plaster one and a half inches in width are applied 
around the joint, and are made to extend some distance 
above and below it, and a gauze bandage is next applied 
over the straps, and the patient is allowed to use the part 
as soon as he can do so without discomfort. 

In the chronic stage of a sprain, after all dressings have 
been removed, the methodical use of massage is often most 
beneficial; and after the parts have been thoroughly 
manipulated a flannel bandage should be applied which, by 
its elasticity, gives a certain amount of support to the parts. 



SPEAINS. 317 

Sprain-fracture. — Under this name Mr. Callender has 
described an injury which consists in the separation of a 
ligament or tendon from its point of insertion, with the 
detachment of a thin shell of bone; this injury is apt to 
occur about the ankle-, knee , elbow-, and wrist-joints, and 
the treatment is the same as that of an ordinary fracture 
in the same locality. This injury is probably much more 
common than is generally supposed in connection with 
sprains of the joints, and is, I think, in many cases the 
cause of the tardy restoration of the function of sprained 
joints, this injury being overlooked and the injury simply 
being treated as a sprain, and the patient being encouraged 
to use the part before the union of the bone has been 
accomplished. 

Strains of muscles and fascia varying in severity from 
simple stretching of the fibres to absolute rupture are 
treated by putting the parts at rest and by the application 
of pressure by means of adhesive straps or of a bandage; 
in strains of the muscles and fascia of the back the use of 
broad strips of adhesive plaster, applied as in cases of 
fracture of the ribs, will be found most satisfactory, and in 
the treatment of the latter stages of the injury the employ- 
ment of massage will often be followed bv good results. 



PAET III. 

FRACTURES. 



In the following article the author has endeavored to 
confine himself simply to a description of the varieties of 
fracture and to their dressing and treatment, and he has 
tried as far as possible to avoid the multiplication of dress- 
ings, being satisfied to describe a few of the methods of 
dressing most frequently employed. He has also avoided 
the description of complicated splints and dressings, by 
the use of which in certain fractures most excellent results 
are obtained, but has preferred to recommend the employ- 
ment of simple splints and dressings, which can be obtained 
by physicians practising in districts remote from large 
cities where the services of an instrument-maker cannot 
be obtained to construct special apparatus for the treat- 
ment of these injuries. 

Varieties of Fracture. 

A complete fracture is one in which the line of separa- 
tion completely traverses the bone, involving the entire 
thickness of the bone. 

An incomplete fracture is one in which there is only a 
partial separation of the bone-fibres (Fig. 219), under 
which name are included partial or " green-stick" fracture, 
in which some of the bone-fibres have given way, while 
the remaining fibres have been bent by the force and have 
not been broken. (Fig. 220.) Fissured, punctured, in- 



VARIETIES OF FBACTUBE. 



319 



dented, and perforating fractures are also included in the 
class of incomplete fractures. (Fig. 221.) 

A simple or closed fracture is a fracture in which there 
are but two fragments, and the seat of injury in the bone 



Fig. 219. 



Fig. 220. 



Fig. 221. 






Incomplete fracture 
of femur. 



Partial or green-stick 
fracture of radius. 



Fissured fracture 
of the humerus. (Gurlt.) 



does not communicate w r ith the external air by a wound in 
the soft parts. 

Compound or open fractures are fractures in which the 
seat of injury in the bones communicates with the external 
air by a wound in the soft parts. 

Comminuted fractures are those in which there are more 
than two fragments, the lines of fracture intercommuni- 
cating with each other. (Fig. 222.) 

A multiple fracture is one in which a bone is the seat of 



320 



FRACTURES. 



two or more distinct fractures at different points, the lines 
of fracture not necessarily communicating with each other. 
Complicated fractures are such as are accompanied by 
some serious injury of the parts in the region of the frac- 
ture — as, for instance, the laceration of important blood- 
vessels or nerves, contusion or laceration of the muscles, 
or dislocation of a neighboring joint. 



Fig. 222. 



Fig. 224. 




Comminuted fracture 
of patella. 

Fig. 223. 





Impacted fracture. 



Transverse fracture 
of femur. (Gurlt.) 



Impacted fractures are those in which one fragment is 
driven into and fixed in the other, the impaction taking 
place at the time of fracture, or being caused by a force 
subsequently applied. (Fig. 223.) 



DIRECTION OF FRACTURE. 



321 



Direction of Fracture. 

A transverse fracture is one in which the geueral line of 
division of the bone is at right angles with the long axis 
of the bone. (Fig. 224.) Transverse fractures of the long 
bones are rarely met with, the line of fracture usually being 
more or less oblique 



Fig. 225. 



Fig. 226. 




Oblique fracture of humerus. 
(Stimson.) 



Longitudinal fracture of tibia. 
(Stimson.) 



An oblique fracture is one in which the line of separa- 
tion is oblique to the long axis of the bone. This is one 
of the most common directions of the line of fracture. 
(Fig. 225.) 

A longitudinal fracture is one in which the line of sepa- 
ration runs in the general direction of the long axis of the 



322 FRACTURES. 

bone. (Fig. 226.) This form of fracture is rare, but is 
sometimes met with in the long bones as the result of gun- 
shot injury. 

Epiphyseal fracture or separation occurs before complete 
ossification has taken place between epiphysis and diaphy- 
sis, and is rarely seen after the twentieth year of life ; 
the direction of the epiphyseal separation is transverse. 
(Fig. 227.) 

Fig. 227. 




Epiphyseal fracture of the head of the humerus. (Moore.) 

The deformity or displacement in fractures is either 
angular, transverse, longitudinal, or rotary. 

Repair of Fractures. 

The process of repair in cases of fracture is concisely 
stated by Ashhurst as follows: "The traumatic irritation 
propagated from the broken bone causes swelling of the 
periosteum, active proliferation, and formation of a sheath 
of new bone around the seat of fracture; this is the 



EXAMINATION OF CASES OF FRACTURE. 323 

ensheathing or ring callus of surgical writers. At the 
same time, the medulla feels the effect of the irritation, 
becomes hardened, and partially ossified ; this constitutes 
the interior or pin callus. Lastly, the osseous tissue itself 
undergoes cell-proliferation, and union of the fragments 
takes place — mutatis mutandis — precisely by the same pro- 
cess that we have already studied in considering wounds of 
the soft tissues. The new material which is thus devel- 
oped between the fragments themselves, constitutes what 
Dupuytren called the intermediate, permanent, or definitive 
callus, in contradistinction to the ensheathing and interior 
forms of callus, which are temporary or provisional." 

Examination of Cases of Fracture. 

In examining a case of fracture to locate the nature and 
seat of the injury, the clothing should be removed from the 
part with as little disturbance as possible, and it is better, 
in most cases, to cut or rip the clothing, rather than to 
attempt to remove it in the ordinary manner. The surgeon 
should first inspect the injured part, and, where possible, 
compare it with its fellow, as in the case of injuries of the 
extremities; much valuable information is also derived 
from the patient or his friends as to the manner in which 
the injury was produced. The part should next be care- 
fully examined by the surgeon ; if it be one of the ex- 
tremities which is injured, it should be gently lifted, firm 
extension being made at the same time, the surgeon by his 
touch and by gentle movements seeking to locate the seat 
of fracture ; and he may, by his manipulation, at the same 
time develop crepitus. 

All manipulations should be made with care, and with 
the greatest gentleness, not only to save the patient from 
pain, but also to prevent the soft parts in the region of 
the fracture from being injured by the rough or sharp 
fragments of the bone. Rough handling of fractures may 
increase the muscular spasm by the irritation caused by 
the sharp fragments of the bones, and may also result in 



324 FRACTURES. 

the injury of important vessels and nerves, and indeed a 
simple fracture may be converted into a compound one by 
forcible and injudicious manipulations. 

The sooner the examination is made after the fracture 
has occurred the better, for at this time there is less swell- 
ing in the region of the injury, and the surgeon can locate 
the bony prominences with much more ease, and can often 
discover the exact seat of the fracture with the least 
amount of manipulation of the parts. When a case of 
suspected fracture is not subjected to examination for 
several days after the reception of the injury, the parts in 
the region of the supposed fracture are often so much 
swollen that it is impossible to accurately locate its seat, 
and in such a case it is often necessary to wait until the 
swelling has subsided before the position of the fracture 
can be satisfactorily fixed, the case being treated in the 
meantime as one of fracture. 

Ancesthetics may be employed to relieve the patient from 
pain and to obliterate muscular spasm in the examination 
of fractures. Their employment is often of the greatest 
service in the diagnosis of obscure or complicated frac- 
tures, especially those in the neighborhood of joints ; but 
the surgeon should remember that all manipulations should 
be made with the same gentleness as when the examination 
is conducted without anaesthesia, for there is the same risk 
of injury to the surrounding structures by the fragments ; 
this precaution is often neglected when an anaesthetic has 
been given, the surgeon often being inclined to handle the 
parts more roughly than he otherwise would ; such practice 
cannot be too severely condemned. 

Provisional Dressings in Cases of Fracture. 

It generally happens that fractures occur at localities 
more or less distant from the point where the treatment 
of the fracture is to be conducted, and the transportation 
of the patient and the temporary dressing of the fracture 
are, therefore, matters of the first importance. In frac- 



PROVISIONAL DRESSINGS IN FRACTURE. 325 



Fig. 228. 



tures of the upper extremities, if the fracture be simple, 
the clothing need not be removed, and the arm should be 
bound to the side by some article of clothing, or supported 
in a sling made from handkerchiefs or the clothing, and 
the patient can usually walk or ride for a short distance 
without much injury to the parts in the region of the 
fracture or inconvenience to himself. When the bones ot 
the lower extremities or the trunk are the parts involved, 
the transportation of the patient 
is a matter of more difficulty. 
When the bones of the trunk 
are involved the part should 
be surrounded by a binder 
firmly pinned or tied, made 
from the clothing or from 
towels, or sheets or other strong 
materials which are at hand. 
When the bones of the lower 
extremity are involved if the 
fracture be a simple one, the 
clothing need not be removed, 
and the motion of the frag- 
ments should be prevented by 
applying to the sides of the 
limb, extending above and be- 
low the seat of fracture, strips 
of wood, shingles, pasteboard, 
bundles of straw, strips of bark 
taken from trees, or bundles of 
twigs, these being held in place 
by handkerchiefs or strips torn 
from the clothing. Umbrellas 
or canes, or broomsticks (Fig. 
228), applied in the same man- 
ner, may be employed, the object of any of these dressings 
being to secure temporary fixation of the fragments of 
bone during the transportation of the patient. 

If the fragments are not fixed in some way, but are 
allowed to move about during the transportation of the 

15 




Provisional dressings for fracture 
of the leg. (Esmarch.) 



326 FRACTURES. 

patient, much damage may result to the soft parts sur- 
rounding the fractured bones, and simple fractures may 
become compound ones by the bones being forced through 
the skin, the discomfort of the patient at the same time 
being much increased. 

Having applied any dressing to bring about fixation of 
the fragments, the patient should next be placed upon a 
broad board or settee ; if a mattress cannot be obtained, 
the fractured limb should be laid upon a mass of clothing, 
or upon some straw, and he should be placed in a wagon 
or carried to the point where the subsequent treatment of 
the fracture is to be conducted. 



Reduction or Setting of Fractures. 

This should be effected as soon as possible after the 
occurrence of the injury and as soon as the surgeon is 
prepared to apply the dressings to keep the parts in their 
proper position; reduction at an early period is less painful 
to the patient and is accomplished with more ease to the 
surgeon than at a later period, when marked swelling and 
inflammation are present at the seat of fracture. Reduction 
consists in bringing the fragments, by manipulation, as 
nearly as possible in their normal position, and it is accom- 
plished by extension and manipulation with the hands, care 
being taken to use as little force as possible to attain the 
object. Very little force is required if the surgeon places 
the part in such a position as to relax the muscles which 
produce the displacement; when this is accomplished the 
fragments can usually be pressed into position by the 
fingers without the application of any considerable force. 
When the reduction of a fracture has been accomplished 
the fragments are retained in position by the application 
of various splints or dressings which serve to prevent their 
displacement. 



FRACTURE DRESSINGS. 327 

Materials and Appliances Used in the Dressing 
of Fractures. 

The Fracture Bed. 

Many ingenious forms of beds have been devised for 
the use of patients suffering from fractures of the bones 
of the trunk and lower extremities, but a simple bedstead 
provided with a firm hair mattress having a perforation 
near its centre, into which is fitted a firm pad, and pro- 
vided with a pan which slides in a framework beneath a 
corresponding opening in the bedstead, will prove a useful 
appliance. The mattress is covered by a sheet perforated 
to correspond to the opening in the mattress, and when 
the pad is removed the evacuations of the patient are 
passed into the pan. 

In fractures of the trunk or lower extremities it will be 
found more convenient in handling the patient to use a 
single bed not over thirty-two or thirty-six inches in 
width, and it is not essential that the mattress be perfor- 
ated, as a bed-pan can usually be slipped under the patient ; 
the mattress should be a firm one stuffed with hair. The 
use of an ordinary tin pie-plate covered w x ith a piece of 
old muslin to receive the fecal evacuations may be substi- 
tuted for the bed -pan and will be found in many cases 
more satisfactory, especially in the case of children suffer- 
ing from fracture of the lower extremity. 

Splints.. 

After the reduction or setting of the fragments in cases 
of fracture they are usually retained in position until 
union occurs by the use of splints held in position by 
means of bandages or strips of muslin. Splints may be 
made of wood, or of tin, lead, copper or wire, binder's 
board, leather, felt paper, or gutta-percha. 

Wooden splints. — The simplest and best splints are made 
from wood — white pine, w r illow or poplar being the best 
material to employ for their construction, being sufficiently 



328 FRACTURES. 

strong to give fixation to the parts and at the same time 
being light. Splints made from smooth white pine, willow 
or poplar boards from one-eighth to one-half an inch in 
thickness may be employed in the form of straight or 
angular splints, and their preparation is a matter of little 
difficulty. 

Wooden splints before being applied to the part should 
be well padded with cotton, wool, oakum, or hair, and 
where lateral wooden splints, are employed in the treat- 
ment of fractures of the lower extremity it is usual to 
place bandages or junk-bags between the limb and the 
splint. The carved wooden splints which are sold by the 
instrument-makers are not to be recommended, as a rule, 
for unless the surgeon has a large number to select from 
it is rare that a splint can be obtained to accurately fit any 
individual case. 

Binder's board or pasteboard, is an excellent material 
from which to construct splints ; it is first soaked in boil- 
ing water, and when sufficiently soft is padded with cotton 
or a layer of lint and moulded to the part. It may be 
secured in position by a bandage ; as it becomes dry it 
hardens and retains the shape into which it was moulded. 

Undressed leather is also an excellent material from 
which to construct splints ; it is applied by first soaking 
the leather in boiling water, and after padding it with 
cotton or lint it is moulded to the part and retained in 
position by a bandage. 

Felt made from wool saturated with gum shellac, pressed 
into sheets, is also a good material from which to con- 
struct splints. This material is prepared for application 
to the surface by heating it before a fire until it becomes 
pliable, or by dipping it into boiling water. 

Gutta-pereha splints made from sheets of this material, 
in thickness from -^ to ^ of an inch, may often be em- 
ployed with advantage ; it is prepared for use by immers- 
ing it in hot water, when it becomes soft and can be 
moulded to the surface. Care should be taken that it is 
not allowed to become too soft by too long immersion to 
permit of its being conveniently handled. 



FRAC1 UBE DRESSINGS. 



329 



Paper splints made from layers of manilla paper stiffened 
with starch constitute a very fair substitute for some of the 
varieties of splints previously mentioned. 

Flaster-of- Paris, starch, chalk and gum, silicate of potas- 
sium or sodium may be employed for the construction of 
splints, either movable or immovable, in the treatment of 
fractures ; their method of preparation and application is 
described (p. 101 et seq.); the plaster-of-Paris dressing is 
the one which is most generally used at the present time. 

Fracture-box. — This is a form of splint used in the 
treatment of fractures of the lower extremity, and con- 
sists of a piece of board eighteen to twenty inches in 
length, with a foot-board firmly secured at its lower 



Fig. 229. 




Fracture-box with movable sides. 

extremity ; the sides are secured by hinges which allow 
them to be raised or lowered (Fig. 229). A fracture-box 
of greater length is required for the treatment of fractures 
about the knee-joint. 

Bran, Sand, or Junk Bags. 

These are constructed by taking a piece of unbleached 
muslin five feet in length and fourteen and one-half inches 
in width, doubling it and securing the free margins, except 
at the mouth, by stitches so as to form a bag ; the bag is 
then inverted so that the edges of the seams are brought 
in the inner surface of the bag. The bags are next filled 
w^ith dry sand, bran, or hair, or with straw, and the mouth 
of the bag is closed by stitches or by being tied with a 
string. Bran bags with splints or sand bags are fre- 
quently employed in the treatment of fractures of the 
femur. 



330 FBACTURES. 

Bandages made of muslin are used to retain splints in 
the treatment of fractures, and are also sometimes applied 
directly to the injured part before the application of splints 
to control muscular spasms and limit the amount of swell- 
ing ; when a bandage is so used it is known as a "primary 
roller. The use of the primary roller is sometimes of the 
greatest service in the dressing of fractures ; but its use in 
inexperienced hands has often been followed by such un- 
fortunate results in the early treatment of fractures, or in 
cases which are not under constant observation, that I 
think it is a safe rule of practice to discard entirely the 
use of the primary roller. 

Compresses made from a number of folds of lint, or ot 
cotton or oakum, are often employed to retain fragments 
in position or to make localized pressure upon certain 
points in the treatment of fractures. The compresses are 
held in position by strips of adhesive plaster, by a few 
turns of a roller bandage, or by the splints. Compresses 
are sometimes employed to protect bony prominences of 
the skeleton from the pressure of the splints; but this 
purpose is often better effected by the use of small pieces 
of soap plaster spread on chamois skin fitted over the 
prominent points. 

Fig. 230. 




Rack for supporting bed-clothes in fracture of the lower extremity. 

A rack or cradle, made of wire or wooden hoops, is often 
employed to support the weight of the bed-clothes in the 
treatment of fracture of the lower extremity (Fig. 230). 

Use of Evaporating Lotions in Cases of 
Fracture. 

The employment of evaporating lotions such as lead- 
water and laudanum, or muriate of ammonia and lauda- 



FRACTURE OF THE NASAL BONES. 331 

num, to the skin in the region of fractures is highly recom- 
mended by many surgeons, especially in fractures involv- 
ing or situated near joints. It is here employed to relieve 
pain, to limit inflammatory swelling, and to hasten the 
absorption of the blood and serum at the seat of fracture. 
Many surgeons, on the other hand, think that their use 
causes irritation of the skin and delays the process of 
repair in the union of the fracture, and so strongly con- 
demn their employment. I personally have never seen 
any bad results arising from their use, and have generally 
employed them in fractures near or involving the joints, 
but I do not consider their employment absolutely essen- 
tial, and when I use them I only do so for two or three 
days. In cases of fractures accompanied with much pain 
and swelling, when the surgeon does not wish to use any 
of the lotions before named, an ointment of ichthyol one 
part, lanoline three parts, spread on lint and wrapped 
around the limb, will often prove a satisfactory dressing, 
or a layer of cotton may be simply wrapped around the 
part before the application of the splints. 



Dressing of Special Fractures. 
Fracture of the Nasal Bones. 

Fractures of the nasal bones are often accompanied with 
fractures involving the septum, the nasal process of the 
maxillary bone, and the nasal spine of the frontal bone. 

The treatment consists in replacing the fragments, if 
displacement exists, by manipulation with the fingers over 
the seat of fracture and by pressure made from within the 
nostrils by a probe or a steel director. When the displace- 
ment is ouce corrected it is not apt to recur, and in the 
majority of cases no dressing is required. Before resort- 
ing to any manipulation within the nasal cavities the 
mucous membrane should be thoroughly cocainized to 
render the operation painless to the patient. When there 
is depression of the fragments or displacement of the 



332 



FRACTURES. 



septum after correcting the deformity by raising the de- 
pressed fragment or bending the septum into place by a 
director, the parts may be held in position by packing the 
nasal cavity firmly with a strip of antiseptic gauze. 

In lateral displacements of the nasal bones from frac- 
ture, after reducing the displacement, a small compress 
held over the fragment by strips of adhesive plaster will 
be the only dressing required. 



Fig. 231. 




Mason's dressing for fractures of the nasal bones. 



Mason transfixes the nose, after reduction of the frag- 
ments, with a stout needle, and steadies the pieces with a 
strip of plaster crossing the bridge of the nose and fastened 
to the ends of the needle. The needle is kept in position 
for eight or ten days (Fig. 231). Roberts, in cases in 
which there is a displacement of the cartilaginous portion 
of the nose, after reducing the deformity, holds the parts 
in position by transfixing them with steel pins. 

Profuse hemorrhage sometimes occurs after fracture of 



FRACTURE OF THE UPPER MAXILLA. 333 

the nasal bones and may require plugging of the nares to 
control it. 

Fractures of the nasal bones are usually firmly united 
in from ten to twelve days, and dressings may be dispensed 
with after this time. 

Fracture of the Malar Bone and Zygoma. 

These fractures are usually the result of direct force ; 
the displacement is upward or backward, and w r hen the 
zygomatic arch is broken the fragments from pressure 
upon the masseter muscle or on the tendon of the temporal 
muscle may interfere with the movement of the lower jaw 
in mastication. This displacement is corrected by cutting 
down upon the fragment and elevating it or by passing a 
tenaculum into the fragment and raising it. 

Outward displacements may be corrected by pressure 
and the application of a compress. The dressing of these 
fractures after the correction of the deformity consists in 
the application of a compress of lint over the seat of frac- 
ture, held in position by strips of adhesive plaster or a 
bandage. There is little tendency to recurrence of the 
deformity after it has been corrected, and union at the seat 
of fracture is usually firm at the end of three weeks. 

Fracture of the Upper Maxilla. 

These fractures may involve the body, the nasal pro- 
cesses, or the alveolar processes. The displacement should 
be corrected, and if any teeth have been displaced they 
should be replaced ; if there is comminution of the alveolus 
the teeth in the separate fragments may be fastened together 
by fine wire to fix the fragments and hold them in place ; 
and the teeth of the lower jaw should be brought up in 
contact with those of the upper jaw, and the jaws should 
be secured together by the application of a Barton's or a 
Gibson's bandage (Fig. 232). Inter-dental splints, made 
of cork, with grooves to fit the teeth, or of gutta-percha, 
are also employed in the dressing of these fractures. The 

15* 



334 FRACTURES. 

patient should not be allowed to move the jaw in mastica- 
tion, and should be nourished by liquid and semi-solid 
food which can be taken without removing any teeth to 
give space for its introduction. 

Fig. 232. 




Dressing for fracture of the upper jaw. 

The bandage should be removed every second or third 
day, and after the face and neck have been sponged off 
with alcohol it should be reapplied. 

These fractures are usually firmly united at the end of 
four or five weeks, and dressings may be dispensed with 
at this time. 

Fracture of the Lower Maxilla. 

The lower jaw may be broken at or near the symphysis, 
the most usual seat of fracture being near the mental fora- 
men ; it is often broken at two places at once, and the frac- 
tures are in many cases rendered compound by laceration 
of the mucous membrane, or the injury may consist in a 
separation of a portion of the alveolar process of the bone. 
The dressing of a fracture of the lower jaw, after reduc- 
ing the displacement and replacing any loosened or de- 
tached teeth, consists in applying a pad of lint under the 



FRACTURE OF THE LOWER MAXILLA. 335 

Fig. 233. 








Dressing for fracture of the lower jaw. 
Fig. 234. 




Four-tailed bandage applied for fracture of the lower jaw. (Hamilton.) 



336 



FRACTURES. 



chin and bringing the jaw up against the upper jaw, hold- 
ing the compress in place, and securing the jaws firmly 
in contact by applying a Barton (Fig. 233), modified 
Barton or Gibson's bandage. The bandage should be re- 
moved and reapplied at the end of the second or third 
day, and at like intervals during the course of treatment. 
The patient should be fed upon a liquid or semi-solid 
diet, not being allowed to chew any solid food until the 
union at the seat of fracture has become firm. 



Fig. 235. 




Fig. 236. 



Shape of splint before being fitted to chin. (Roberts.) 

A very satisfactory temporary dressing for fracture of 
the lower jaw consists in the application of a four-tailed 
sling. (Fig. 234.) 

Some surgeons prefer to use an external splint moulded 
from pasteboard or gutta percha fitted to the chin in the 
dressing of this fracture, this being padded with cotton and 
held in place by a Barton or Gibson 
bandage. (Fig. 236.) Where there is 
much difficulty in keeping the frag- 
ments in position the wiring together 
of the teeth may be employed, or the 
fragments may be perforated with a 
drill and held in place by a strong 
silver - wire suture ; inter - dental 
splints of metal or gutta-percha are 
also sometimes used for this pur- 
pose. During the course of the 
treatment in fracture of the jaws the mouth often becomes 
very offensive from the fermentation of the saliva and dis- 




Splint moulded to fit chin. 
(Roberts.) 



FRACTURE OF THE LARYNX OR TRACHEA. 337 

charges, and it is well to use frequently a mouth-wash of 
chlorate of potash, tincture of myrrh, glycerin, and water. 

The dressings for fracture of the lower jaw are usually 
applied for four or six weeks, the union usually being 
quite firm at the end of this time. 

Fracture of the Hyoid Bone. 

In fracture of the hyoid bone, if displacement exists, its 
reduction is facilitated by pressure made with the finger 
in the pharynx. 

The treatment consists in enforced quiet and the use of 
opium if cough is a prominent symptom, and the inflam- 
matory symptoms may require the employment of active 
local treatment. A dressing may sometimes be employed 
with advantage, consisting of a splint of pasteboard or 
leather moulded to the anterior portion of the neck. 

Fracture of the Larynx or Trachea. 

In fractures of the larynx or trachea where there is little 
displacement and dyspnoea is not marked, the parts should 
be supported by the application of compresses of lint held 
in place by strips of adhesive plaster. If, on the other 
hand, the respiration is embarrassed or there is free expec- 
toration of blood, tracheotomy should be performed, and 
if the injury be seated in the larynx the displacement of 
the fragments may be overcome by manipulation with the 
finger or a director through the tracheal wound, or the 
larynx may be packed with a strip of antiseptic gauze to 
control hemorrhage or hold the fragments in position, the 
patient in the meantime breathing through a tracheotomy- 
tube secured in the tracheal wound ; the packing should 
be removed in a few days, the tracheotomy-tube being 
permanently removed as soon as the patient can breathe 
comfortably through the larynx with the tracheal wound 
closed. In fractures of the trachea the opening into the 
trachea should be below or at the seat of injury. 



338 



FBACTURES. 



Fractures of the Trunk. 



Fig. 237. 



Fractuke of the Ribs. 

Fractures of the ribs are more frequent than fractures 
of any other bones of the trunk; the ribs most commonly 
broken are those from the fourth to the tenth ; the most 
common seat of fracture is near the junction of the costal 
cartilages or at the angle. The dressing of fractures of the 
ribs is best accomplished by envel- 
oping the side of the chest on which 
the rib or ribs are broken with 
broad straps of adhesive plaster. 
The adhesive straps should be two 
and a half inches in width and 
long enough to extend from the 
spine to the middle of the sternum. 
The straps are warmed and the 
first strap is firmly applied a short 
distance below the seat of fracture, 
extending from the spine to the 
mid-sternal line ; a number of as- 
cending straps are applied in this 
way, each strap overlapping the 
preceding one by about one- third of its width until half 
the chest is covered in. (Fig 237.) This dressing usu- 
ally gives the patient much comfort, and the straps need 
not be renewed until they become slightly loosened, usu- 
ally at the end of a week or ten days ; they should then 
be renewed in the same manner. 

The dressings for fractures of the ribs are usually dis- 
pensed with at the end of three or four weeks, as repair 
of the fracture is generally well advanced by this time. 

A satisfactory temporary dressing for fractures of the 
ribs consists in surrounding the chest by a broad binder of 
stout linen or muslin ; indeed, some surgeons prefer to 
employ this dressing during the course of treatment, but 
as a rule I think it is not as good a dressing as the adhe- 




Adhesive plaster dressing 
for fracture of the ribs. (Ham- 
ilton.) 



FRACTURE OF THE STERNUM. 339 

sive plaster dressing, as the former confines the move- 
ments of both sides of the chest. 



Fracture of the Costal Cartilages. 

These fractures often take place at the junction of the 
cartilages with the ribs or in the body of the cartilages, 
and the union of the fracture usually takes place by the 
production of a mass of bone at the seat of fracture. The 
dressing for fractures of the costal cartilages consists in the 
application of strips of adhesive plaster applied in the 
same manner as for fracture of the ribs, and the dressing 
should be retained for about the same time. 



Fracture of the Sternum. 

Fractures of the sternum are rare injuries, but diastasis 
of the bones of the sternum is a more common accident. 
The dressing for either variety of injury is the same, and 

Fig. 238. 




Adhesive plaster dressing for fracture of the sternum. 

consists in the application of a compress over the seat of 
fracture held in place by a broad bandage, or, better, by 
strips of adhesive plaster (Fig. 238), applied so as to cover 
and fix the anterior portion of the chest, covering the 



340 FRACTURES. 

entire length of the sternum. This dressing should be 
retained for at least four weeks, being renewed if it be- 
comes loose at the end of a week or ten days. 

Fracture of the Pelvis. 

These fractures are often serious injuries from implica- 
tion of the pelvic viscera. The reduction of the displace- 
ment should be first accomplished as far as possible by 
external manipulation, together with internal manipula- 
tion by the fingers introduced into the rectum, or into the 
vagina in the female. The patient should be placed upon 
a firm bed on his back, with the knees slightly flexed over 
a pillow, and the parts should be kept at rest by surround- 
ing the pelvis with broad straps of adhesive plaster or a 
stout muslin binder, or by a firmly applied padded pelvic 
belt. The hip-joints should be kept at rest by the applica- 
tion of pasteboard splints or by sand-bags. The dressings 
should be retained for a period of at least six weeks. 

When these fractures are complicated by injury of the 
pelvic viscera various operative procedures may be re- 
quired, which will compel the surgeon to modify the 
method of dressing. 

Fracture of the Sacrum and Coccyx. 

The dressing of fractures of the sacrum, after effecting 
reduction of the fragments as far as possible by pressure 
from within the rectum, consists in the application of 
broad adhesive straps around the pelvis, and the patient 
should be kept at rest in bed. When the coccyx only is 
fractured, after reduction of the displacement the patient 
should be confined to bed and the bowels should be kept 
at rest by the use of opium by suppository. The patient 
should be kept at rest for three or four weeks, and, in 
case of fracture of the sacrum, the dressings should be 
retained for this time. 



FRACTURE OF THE VERTEBRM 341 

Fracture of the Vertebrae. 

Fractures of the vertebrae are always most serious in- 
juries, not only from the injuries of the bones themselves, 
but also from the damage to the spinal cord, membranes, 
and nerves, which often accompanies them. 

In transporting, or turning in bed, a patient suffering 
from fracture of the vertebrae, great care should be exer- 
cised, for rough or sudden motions might cause a displace- 
ment of the fragments which might, by injury of, or 
pressure upon, the spinal cord, rapidly prove fatal. 

In the treatment of fractures of the spine, if the de- 
formity is marked, efforts should be made to reduce it by 
extension and counter-extension, and the result may be 
successful, especially if the fracture be associated with a 
dislocation of the vertebrae. In some cases the use ot 
permanent extension by means of weights attached to the 
legs, shoulders, and chest by adhesive plaster and bandages 
has been successful in reducing the deformity. 

The patient should be placed upon his back upon a bed 
with a hair mattress, or better, if it can be obtained, a 
water-bed, which consists of a rubber mattress filled with 
water, which distributes the weight of the patient's body 
evenly over the surface. Whatever form of bed be used, 
the greatest care should be exercised to keep the patient 
absolutely clean, and the parts of the body or limbs which 
are exposed to pressure should be frequently bathed with 
alcohol or soap liniment ; and to distribute the pressure, 
small pads should be placed under the parts and changed 
at intervals. These precautions are necessary to prevent, 
if possible, the formation of extensive bedsores, w 7 hich are 
a frequent and troublesome complication of these injures. 

The bowels should be carefully watched, and, if con- 
stipation is present, it should be relieved by the use of 
enemata ; and, as it is not desirable to lift the patient to 
slip a bed-pan under him, the discharges can be received 
in a flat tin plate pushed under the thighs and buttocks, 
or on pads of oakum or old muslin. 

The care of the bladder is also a matter of the greatest 



342 FRACTURES. 

importance ; the retention which at first exists should be 
relieved by the use of a flexible catheter introduced with 
great gentleness, and when incontinence supervenes the 
catheter should also be used at intervals ; the employment 
of a soft instrument, if used with care, is not apt to pro- 
duce any injury to the urethra or bladder. 

The employment of a plaster-of-Paris jacket has been 
followed, in some cases, by good results, and it may be 
applied early in the case, or it may be used after the 
patient has been kept in the recumbent posture for some 
weeks ; by its use it is often possible to get the patient out 
of bed and allow him to sit in a chair. 

In fractures involving the cervical vertebrae, care should 
be exercised in lifting or moving the head, and it is often 
of advantage in these cases to apply short sand-bags to the 
sides of the neck and head, to give additional fixation to 
the parts while the patient is in the recumbent posture, 
or, if he is allowed to get out of bed, to apply a moulded 
leather or pasteboard splint to the neck, shoulders, and 
back of the head for the same purpose. 

Trephining of the spine in cases of fracture of the 
vertebrae, to remedy the displacement and relieve the cord 
from pressure, has been recommended and employed in 
some cases, and although the operation under strict anti- 
septic methods is not attended with much risk, the results 
obtained up to the present time scarcely seem to warrant 
its performance. 

The course of treatment in cases of fractures of the ver- 
tebrae, if the patient does not succumb to the injury in a 
few days or weeks, often extends over many months, and 
recovery is often more or less incomplete as regards the 
function of the parts below the seat of fracture. 

Fracture of the Skull. 

The treatment of fractures of the skull, whether simple 
or compound, depends largely upon the nature of the in- 
jury and the condition of the cranial contents. In simple 
fractures unaccompanied with cerebral symptoms no 



FRACTURE OF THE CLAVICLE 343 

special dressing is required, but in compound fractures 
where loose fragments are present, these should be re- 
moved ; and if there is no depression of the fragments, 
and if no cerebral symptoms are present, the wound 
should be drained, carefully closed and dressed antisep- 
tically, the dressings being held in place by a recurrent 
bandage of the head. 

The patient should be put to bed, and the use of an ice- 
cap to the head is often of service. The diet should be 
restricted, while calomel and opium or bromide of potas- 
sium should be administered ; it is well to keep the patient 
for a few weeks in a quiet and darkened room. Where 
cerebral symptoms are present, either in simple or com- 
pound fractures, and trephining is resorted to, the dressing 
of the wound is similar, and the same general treatment 
should be adopted. In all cases of fracture of the skull, 
whether subjected to operative treatment or not, it is well 
to keep the patient at rest in bed for three or four weeks, 
and he should be cautioned to avoid excesses, and should 
not resume active work for some months. 



Fractures of the Upper Extremity. 

Fracture of the Clavicle. 

Fractures of the clavicle may be complete or incomplete, 
and in the latter variety of injury the deformity is not 
usually very marked. The indications for treatment in 
complete fractures of the clavicle are to relax the sterno- 
cleido-mastoid muscle, to prevent the weight of the arm 
on the injured side from dragging down the outer fragment 
of the clavicle, and, by fixing the scapula, to carry the 
attached external fragment outward and forward. A large 
number of dressings have been devised and used to accom- 
plish these objects. The treatment of fractures of the 
clavicle by position is accomplished by placing the patient 
in bed on his back upon a firm mattress with a low pillow 
under his head, and the arm on the side of injury should 



344 



FRACTURES. 



be fastened to the side of the chest by a few circular turns 
of a bandage passing around the arm and chest ; the de- 
formity is usually very satisfactorily reduced upon the 
patient assuming this position, and after three weeks' rest 
in this position the union is generally sufficiently firm to 
allow the patient to get out of bed and be about with the 
arm bound to the side or carried in a sling or with a Vel- 
peau bandage applied without any recurrence of the de- 
formity. 

A satisfactory temporary dressing for fractures of the 
clavicle consists in the application of a four-tailed ban- 
dage ; the bandage is made from a piece of muslin two 



Fig. 239. 




Four-tailed bandage for fracture of clavicle. (Stimson.) 

yards in length and fourteen inches in width ; a hole is 
cut in its centre about four inches from its margin, to re- 
ceive the point of the elbow ; the bandage is then split 
into four tails in the line of the hole and to within six 
inches of it ; the body of the bandage should be applied so 
that the point of the elbow rests in the hole, and a folded 
towel being placed in the axilla, the lower tails should be 
carried, one anteriorly, the other posteriorly, diagonally 
across the chest and back to the neck on the side opposite 
the seat of fracture, and secured ; the remaining tails are 



FRACTURE OF THE CLAVICLE. 



345 



next carried around the lower part of the chest and secured 
so as to fix the arm to the side of the body. (Fig. 239.) 

In some cases the deformity is corrected by the applica- 
tion of a posterior figure-of-eight bandage, the forearm on 
the side of injury being carried in a sling. (Fig. 240.) 



Fig. 240. 




Posterior figure-of-eight dressing for fracture of the clavicle. (Hamilton.) 



Say re's dressing for fracture of the clavicle consists of 
two strips of adhesive plaster three and a half inches wide 
and two yards in length. The first strip is looped around 
the arm just below the axillary margin, and is pinned or 
sewed with the loop sufficiently open not to constrict the 
arm. The arm is then drawn downward and backward 
until the clavicular portion of the pectoralis major muscle 
is put sufficiently upon the stretch to overcome the action 
of the sterno-cleido-mastoid muscle, and in this way draw T s 
the sternal fragment of the clavicle down to its pace. The 
strip of plaster is then carried completely around the body 
and pinned or stitched to itself on the back. (Fig. 241.) 
The second strip is next applied, commencing upon the 
front of the shoulder of the sound side ; thence it is car- 
ried over the top of the shoulder diagonally across the 



346 



FRACTURES. 



back, under the elbow, diagonally across the front of the 
chest to the point of starting, where it is secured by 
pinning or sewing. A slit is made in this strip to receive 
the point of the elbow. Before the elbow is secured by 
the plaster it should be pressed well forward and inward. 
(Fig. 242.) 



Fig. 241. 



Fig 242. 





Say re's dressing for fracture of the 
clavicle. First strip applied. 



Sayre's dressing for fracture of the 
clavicle. Second strip applied. 



Velpeau's dressing may also be used in the treatment of 
fractures of the clavicle. (Fig. 243.) A compress may 
also be secured by the vertical turns of this bandage over 
the seat of fracture if needed. The application of the 
bandage is described (p. 68). 

In any form of dressing in which the arm is held against 
the side of the chest, it is well to apply a folded towel or 
piece of lint between the arm and chest to prevent the 
surfaces from becoming excoriated. 



FRACTURE OF THE CLAVICLE. 



347 



Fig. 243. 




Velpeau's dressing for fracture 
of the clavicle. 



A modified form of the Velpeau dressing for fracture 
of the clavicle is applied as follows : A soft towel or piece 
of lint is placed agaiust the side 
of the body and over the front 
of the chest, and held in position 
by a strip of adhesive plaster; 
the arm is next placed in the 
Velpeau position, a good-sized 
pad of lint is next applied over 
the scapula, and this is held in 
place by a broad strip of adhesive 
plaster two and a half inches in 
width and one and a half yards 
in length ; this strip is continued 
downward and forward so as to 
pass over the point of the elbow, 
and is carried diagonally across 
the chest to the shoulder of the 
opposite side, and is secured, a 
slit being cut in it to receive the 
point of the elbow; a compress of lint is next placed over 
the seat of fracture and held in place by a strip of ad- 
hesive plaster ; an additional strip of plaster is next car- 
ried from the spine around the arm and chest and secured 
on the opposite side of the chest ; circular turns of a roller 
bandage are then passed around the chest, including the 
arm from below upward until the arm is securely fixed 
to the body, and the dressing is finished by making one 
or two turns of the third roller of Desault. (Fig. 244.) 
Or the turns of the third roller of Desault may be applied 
first, and the dressing may be finished by circular turns 
of a roller passing around the arm and chest, extending 
from the elbow to the shoulder. 

In the treatment of fractures of the clavicle in children 
the Velpeau or modified Velpeau dressing will be found 
to be the most satisfactory dressing to employ, and as these 
patients are particularly apt to disarrange their dressings 
it is well to render the dressing additionally secure by 
applying a few broad strips of adhesive plaster over the 



348 FRACTURES. 

turns of the roller bandage, the strips following the turns 
of the bandage. 

The removal of dressings and their reapplication will 
depend upon the comfort of the patient and the manner 
in which they keep their position. As a rule, in fractures 
of the clavicle the dressings are removed at the end of the 
second or third day, the parts are inspected, and the skin 
is sponged off with dilute alcohol or whiskey ; the dress- 
ings are then reapplied, and if the patient is comfortable 

Fig. 244. 




Modified Velpeau dressing for fracture of the right clavicle. 

and the parts are in good position, the dressings are made at 
less frequent intervals until union is completed at the seat 
of fracture. 

Union in cases of fracture of the clavicle is generally 
quite firm at the end of four or five weeks, and at this 
time the dressings may be removed, and the patient should 
carry the arm of the affected side in a sling for several 
weeks, and should not undertake any work requiring 
forcible movements of the arm until eight or ten weeks 
have elapsed from the receipt of the injury. 



FRACTURE OF THE SCAPULA. 



349 



The time required for union in fractures of the clavicle 
in children is somewhat shorter; the dressings may be 
removed at the end of three weeks. 



Fracture of the Scapula. 

Fractures of the scapula may involve the body, neck, 
acromion or coracoid process of the bone. Fractures of 
this bone are quite rare. 

Iracture of the Body of the Scapula. 

In dressing this fracture, if deformity is present, it is 
reduced by manipulation, and compresses of lint are 
placed above and below the seat of fracture and held in 
place by adhesive strips; the arm is next fixed to the side 
of the body by spiral turns of a roller bandage passing 
around the arm and chest, and the forearm is supported 
in a sling. 

Fracture of the Neck, Acromion or Coracoid Process 
of the Scapula. 

Fig. 245. 




Velpeau dressing for fracture of the scapula. 
16 



350 



FRACTURES. 



These fractures may be dressed by placing a pad of 
lint or a folded towel in the axilla and binding the arm 
to the body by spiral turns of a roller bandage passing 
around the arm and chest and supporting the forearm in 
a sling. Or these fractures of the scapula may be dressed 
by first placing a pad of lint or a folded towel in the 
axilla and then securing the arm in the Velpeau position 
by the application of a Velpeau's bandage. (Fig. 245.) 
In fractures of the acromion or coracoid processes the 
union is usually fibrous. In the treatment of fractures of 
the scapula the dressing should be retained for about four 
weeks. 

Fbacture of the Humerus. 

Fractures of the humerus may involve the upper ex- 
tremity, the shaft or the lower extremity of the bone. 

Fractures of the Upper Extremity of the Humerus include 
fractures of the head and anatomical neck of the bone, 
fractures through the tuberosities, fractures through the 
surgical neck of the humerus, and epiphyseal fracture or 
disjunction of the upper epiphysis of the 
humerus. 

The most satisfactory dressing for all 
fractures of the humerus above the upper 
third of the bone is applied as follows : A 
primary roller should be evenly applied 
from the tip of the fingers to the seat of the 
fracture, the arm being flexed at the elbow 
before the bandage is carried above this 
point, to prevent the dangerous constriction 
which might result if the bandage were 
applied with the arm in the straight posi- 
tion, and it were afterward flexed at the 
elbow. A folded towel or a thin pad of 
lint should next be placed in the axilla and 
over the outer surface of the chest, to fur- 
nish a firm basis of support for the humerus 
and also to prevent excoriation from the contact of the 
skin surfaces. A splint of pasteboard, felt or leather (Fig. 



Fig. 246. 




Moulded splint for 
shoulder and arm. 



FRACTURE OF THE HUMERUS. 



351 



246) is next moulded to the shoulder and arm ; this should 
be long enough to extend some distance below the seat of 
fracture and wide enough to cover in about one-half of the 
circumference of the arm, and is padded with cotton and 
fitted to the shoulder and arm. The splint and arm are next 
secured to the side of the body by spiral turns of a roller 
bandage including the arm and chest in its turns and applied 
from the elbow to the top of the shoulder. The forearm 
is carried in a narrow sling suspended from the neck (Fig. 
247). This dressing should be removed at the end of 

Fig. 247. 




.Dressing for fracture of the upper extremity ol the humerus. 



twenty-four or forty-eight hours, and after the parts have 
been inspected and sponged over with alcohol, the dress- 
ings should be reapplied in the same manner, and if the 
patient is comfortable they need not be disturbed again 
for three or four days, subsequent dressings being made 
at the same intervals. Union in fractures of the upper 
extremity of the humerus, except in intra-capsular fract- 
ure, in which bony union is the exception, is usually quite 
firm at the end of five or six weeks, and the dressings can 
be dispensed with at this time. 



352 



FRACTURES. 



Fracture of the Shaft of the Humerus. 

The dressing consists in the application of a primary 
roller from the tips of the fingers to the seat of fracture ; 
a short well-padded wooden splint extending from the 
axilla to a point a little above the internal condyle is next 
placed on the inner surface of the arm and against the 
chest ; a moulded pasteboard or felt splint, fitted to the 
shoulder and outer side of the arm and extending a short 
distance below the seat of fracture, is padded with cotton 
and applied to the shoulder and arm. The splints are 
held in position by the turns of a bandage, and the arm 
is secured to the body by spiral turns of a roller bandage 

Fig. 243. 




Internal angular splints. 

carried around the chest and arm, and the forearm is 
carried in a sling suspended from the neck. The dressing 
is much the same as that for fracture of the upper part of 
the humerus, with the addition of the short internal splint. 
Fracture of the shaft of the humerus may also be 
dressed by first applying a primary roller and then plac- 
ing the forearm and arm upon a well-padded internal 
angular splint. (Fig. 248.) Care should be taken to see 
that the end of the splint extends only to the axilla and 
does not press upon the brachial veins. A pasteboard or 
felt moulded splint is next applied to the shoulder and 
outer side of the arm, which should be long enough to 



FRACTURE OF THE HUMERUS. 353 

extend below the seat of fracture. The splints are held 
in position by turns of a roller bandage beginning at the 
fingers and carried up to the shoulder, and finished with a 
few spica-of-the-shoulder turns. (Fig. 249.) The arm is 
supported by a sling applied at the wrist, and sometimes 
for additional security the arm is bound to the side of the 
body by spiral turns of a bandage carried around the arm 
and chest. The after-treatment of these fractures as re- 

FlG. 249. 




Dressing for fracture of the shaft of the humerus with internal angular splint 
and external splint of binder's board. 

gards the removal and renewal of the dressings is the same 
as in cases of fracture of the upper portion of the humerus. 
In fractures of the shaft of the humerus the dressings 
should be retained for five or six weeks. 

Fracture of the Lower Extremity of the Humerus. 

These include fractures at the base of the condyles, 
splitting fractures between the condyles or those of the 
internal or external condyle, and epiphyseal fracture or 
disjunction of the lower epiphysis of the humerus. 



354 



FRACTURES. 



In dressing fractures of the lower extremity of the 
humerus, if a primary roller is employed it should be 
carried up only to the elbow. The displacement is reduced 
by extension and manipulation, and before applying any 
splint it is well in many cases to apply over the region of 




Anterior angular splint. 

the fracture several folds of lint saturated with lead- water 
and laudanum, and to cover this dressing with waxed 
paper or rubber tissue to diminish as far as possible the 
swelling, which is very marked after these injuries. The 
use of this lotion may be omitted, and a layer of cotton 

Fig. 251. 




Dressing for fracture of the lower extremity of the humerus with anterior 
angular splint. 

may be placed around the joint in its place. An anterior 
angular splint (Fig. 250) well padded with cotton or 
oakum is next applied and held in position by the turns 
of a roller bandage applied from the fingers to the upper 
portion of the splint. (Fig. 251.) These fractures may 




FRACTURE OF THE HUMERUS. 355 

also be dressed with a well-padded internal angular splint, 
this splint being substituted by an anterior angular splint 
at the end of ten days or two weeks. 

These fractures may also be dressed by placing the arm 
in a posterior angular trough (Fig. 252) made of paste- 
board or leather. Some surgeons prefer to dress fractures 
of the condyles of the humerus with the arm in the ex- 
tended position upon a straight an- 

m. M. O "Fir" 9^9 

terior splint, or with short, narrow 

pasteboard splints applied around 

the joint, as favoring more accurate 

coaptation of the fragments. If 

this position is employed a straight 

wooden splint is applied to the 

anterior surface of the arm and 

forearm, or moulded splints of Posterior angular trougK 

pasteboard may be used, and after 

the union is moderately firm, at the end of two weeks, the 

elbow should be flexed and kept in this position during 

the remaining time of the treatment. 

When fractures of the lower extremity of the humerus 
involve the elbow-joint a certain amount of impairment of 
joint-motion is apt to occur either from ankylosis or from 
displacement of the fragments which in many cases it is 
impossible to completely reduce, so that flexion and exten- 
sion of the joint are restricted. Bearing these facts in mind, 
it is well to make passive motion in these cases as early 
as the second or third week. It is well to explain to the 
patient or his friends that impairment of joint-motion may 
result in these fractures in spite of the greatest skill and 
care in the treatment. In a case of fracture in the region 
of the condyles of the humerus the dressings should be 
removed in twenty-four hours, and it should be re-dressed 
in the same manner, and if the swelling does not increase 
and the dressing is comfortable to the patient it should 
afterward be dressed at less frequent intervals ; the union 
is generally quite firm at the end of four w T eeks, and the 
splint may be removed at this time. Fractures of the 
condyles of the humerus are very common in children, 



356 FRACTURES. 

and epiphyseal disjunctions of the lower epiphysis of the 
humerus are also met with ; the dressing of these injuries 
in this class of patients is similar to that described for 
fractures of the condyles of the humerus. 

Fracture of the Olecranon Process of the 
Ulna. 

Fractures of the olecranon may consist in simply a 
separation of the cortical layer of bone over the summit 
of the process to which the triceps is principally attached, 
or the line of fracture may pass through the sigmoid fossa. 

Fractures of the olecranon are dressed with the arm 
slightly flexed at the elbow, or with it completely extended, 

Fig. 253. 




Adhesive strap applied to draw fragment downward. 

the former position is possibly a little less irksome to the 
patient. The separation of the fragment by the action of 
the triceps muscle is usually not very marked ; but, if the 
displacement is considerable, it may in a measure be over- 
come by the use of a compress above the fragment, over 
which figure-of-eight strips of adhesive plaster are fastened 
to draw it down into position (Fig. 253.) The ends of the 
strap are then attached to a well-padded straight splint 
which should be long enough to extend from the upper 
third of the arm to the ends of the fingers, which is 
secured in position by the turns of a roller carried from 
the fingers to the upper extremity of the splint, with figure- 



FRACTURE OF THE OLECRANON. 357 

of-eight turns at the elbow to reinforce the action of the 
strips of plaster. 

This fracture may also be dressed by first applying a 
primary roller up to the elbow, and then placing the arm 
upon a well-padded anterior obtuse-angled splint, or a 
straight splint with a good-sized pad of lint or oakum 
fastened at a point corresponding to the position of the 
flexure of the elbow. When either of these splints is 
placed upon the arm a position of moderate flexion is 
obtained. A compress of lint is next placed above the 
fragment, if there is a displacement, and one or two narrow 
strips of adhesive plaster are fastened over this and passed 
obliquely downward and attached to the splint on either 
side. The splint is then securely fastened to the arm by 
the turns of a roller bandage applied from the fingers to 
the upper end of the splint. (Fig. 254.) 

Fig. 254. 




Fracture of olecranon dressed in the extended position. 

The dressings in a case of fracture of the olecranon 
should be removed at the end of twenty-four or thirty-six 
hours, or sooner if there is evidence of swelling of the 
tissues in the region of the fracture, and they should be 
reapplied in the same manner. If the dressing is com- 
fortable to the patient, and there is no evidence of swell- 
ing, the subsequent dressings should be made at less frequent 
intervals ; the dressings are usually retained in this frac- 
ture for five or six weeks. Passive motion should not be 
made until this time, as flexion of the elbow tends to 
separate the fragments, unless union has taken place. The 
repair of a fracture of the olecranon is, in most cases, by 

16* 



358 FRACTURES. 

fibrous union, but in a few instances bony union has been 
found to have taken place. 



Fracture of the Coronoid Process of the Ulna. 

Fractures of the coronoid process are rarely met with, 
and their dressing is accomplished by placing the arm in 
a flexed position and applying a well-padded internal 
right-angled splint, or a posterior right-angled splint, and 
securing it to the arm by the turns of a roller bandage. 
A moulded pasteboard or leather gutter may be substituted 
for the angular splints. The dressings should be changed 
at intervals, and after their removal, at the end of three or 
four weeks, passive motion should be practised. 

Fracture of the Head and Neck of the Radius. 

These fractures are also quite rare, and, when met with, 
should be dressed, after reducing the fragments by manipu- 
lation, by flexing the elbow and keeping it in this position 
by the application of a well-padded anterior right-angled 
splint, the splint being firmly secured in position by the 
turns of a roller bandage applied from the tips of the 
fingers to the upper end of the splint. The splint should 
be changed at intervals, and should not be permanently 
removed for four weeks, at which time passive motion, 
consisting in flexion and extension at the elbow and 
pronation and supination of the forearm, should be made. 
(Fig. 251.) 

An internal angular splint applied to the inner surface 
of the forearm and arm may also be used in the treatment 
of these fractures. (Fig. 249.) 

Fracture of Both Bones of the Forearm. 

These fractures are often met with as the result of direct 
or indirect violence, and after reducing the displacement, 
which is always marked when both bones are broken, and 



FRACTURE OF BOTH BONES OF THE FOREARM. 359 

is not so marked when one bone only is broken, by making 
extension from the hand and by manipulation ; the forearm 
is placed in the supine position or in a position between 
pronation and supination. The supine position is, as a 
rule, to be preferred in any fracture of the radius, as the 
upper fragment is supinated by the action of the biceps 
and supinator brevis muscles, and, therefore, unless the 
lower fragment be placed in the supine position, union 
with the rotary deformity will almost inevitably ensue. 

Two straight wooden splints, well padded, a little wider 
than the forearm, are employed. The anterior splint 

Fig. 255. 




Dressing for fracture of both bones of the forearm. 

should be long enough to extend from the elbow to the 
tips of the fingers, and the posterior splint should extend 
from the elbow to the wrist. A primary roller should 
never be applied to the forearm in dressing these fractures, 
as its application diminishes the interosseous space, and its 
use has been followed by gangrene of the hand and fore- 
arm. In applying the anterior splint to the palmar surface 
of the forearm and hand, care should be taken to see that 
the upper end of the splint does not press upon the bra- 
chial artery and basilic vein at the elbow when the forearm 
is flexed ; the posterior splint is next applied from the 
elbow to the wrist, and the splints are held in position by 
the turns of a bandage carried from the fingers to the 
elbow. (Fig. 255.) 



360 FRACTURES. 

In dressing this fracture a posterior splint equal in 
length to the anterior splint may be used in place of the 
short posterior splint extending from the elbow to the wrist. 

In fracture either of the shaft of the radius or of the 
ulna alone, the deformity is usually not so marked as when 
both bones are broken at the same time, the unbroken 
bone acting as a splint ; the dressing for these fractures is 
the same as for fracture of both bones of the forearm. 

The dressing should be removed in twenty-four or thirty- 
six hours, and after inspecting the parts and sponging 
them with dilute alcohol the splints should be replaced in 
the same manner and secured. The dressing should be 
removed and renewed at intervals of two or three days for 
two weeks at least, and after this time the dressings should 
be made at less frequent intervals. The time required for 
union in these fractures is usually five or six weeks, and 
the splints should be retained for this time. 

Fractures of the forearm should be seen by the surgeon 
frequently for the first two weeks of the treatment, for it 
is in these fractures that the most unfortunate results have 
occurred from neglect of this precaution. 

In children incomplete or green-stick fracture of the 
bones of the forearm are very common ; their dressing, 
after reducing the deformity, which consists in bending 
the bones back into place, often converting the incom- 
plete fracture into a complete one, is accomplished in the 
same manner as described above. In these patients there 
is a great tendency to displace the splints or rather to draw 
the forearm out of the splints, and to prevent this I often 
employ an anterior angular splint, in place of the straight 
anterior one, the upper portion of which, being fastened 
to the arm, prevents the child from dragging the arm out 
of the dressings. 

Fracture of the Lower End op the Radius. 

The most common fracture of the radius is one situated 
from one-half of an inch to one and one-half inches above 



FRACTURE OF THE LOWER END OF THE RADIUS. 361 

the lower articular surface of the bone, the line of fracture 
being more or less transverse, although it may in some 
cases be slightly oblique ; the characteristic deformity in 
this fracture is represented in Fig. 256. 

Fig. 256. 




Fracture of the radius near its lower extremity. 

The most important point in the treatment of this frac- 
ture is to effect complete reduction before the application 
of any splint ; this is done by making extension from the 
hand, and, at the same time, by extending and flexing the 
wrist and by manipulation, the deformity can usually be 
completely reduced. The arm should then be brought 

Fig. 257. 





Position of compresses in Colles's fracture. 

into the position of supination, and a firm compress of lint 
is next placed over the lower end of the upper fragment 
on the palmar surface of the forearm ; a second compress 
is then placed over the upper end of the lower fragment 
(Fig. 257), and a well-padded Bond splint (Fig. 258) is 
applied to the palmar surface of the arm and held in place 
by the turns of a roller bandage. (Fig. 259.) 



362 FRACTURES. 

Many surgeons treat this fracture with the hand in a 
position between pronation and supination, the thumb 
pointing upward. A substitute for Bond's splint may be 

Fig. 258. 




Bond's splint. 
Fig. 259. 




Dressing for fracture of the lower end of the radius. 
Fig. 260. 




Substitute for Bond's splint. 



prepared by fastening a roller bandage obliquely upon 
a straight wooden splint as suggested by Dr. Hays. 
(Fig. 260.) 



FRACTURE OF THE CARPAL BONES. 363 

Two straight splints with compresses are also employed 
in the treatment of this fracture, and a vast number of 
splints have been devised ; among these may be mentioned 
those of Gordon, Coover, and the metal splint of the late 
Dr. R. J. Levis. The most important point in the treat- 
ment of this fracture is the complete reduction of the 
deformity at the first dressing, and if this has been satis- 
factorily done almost any splint may be used with a good 
result, and indeed some surgeons use no splint, applying 
only a compress over the palmar fragment, held in place 
by a strip of plaster, the arm being carried in a sling. 

The after-treatment of these fractures consists in remov- 
ing the splint and compresses after twenty-four or thirty- 
six hours and in sponging the surface of the skin with 
dilute alcohol, and the compresses and splint should then 
be reapplied in the same manner ; the fracture should be 
dressed every second or third day for the first two weeks, 
and after this time it should be dressed at less frequent 
intervals. Union is usually quite firm at the end of four 
weeks, and the splint should be dispensed with at this 
time. A certain amount of stiffness of the wrist and 
fingers is apt to follow this fracture, which is usually 
soon overcome by passive motion and physiological use of 
the parts. 

In children epiphyseal separations or fractures of the 
lower epiphysis of the radius are often met with, and their 
treatment is similar to that described above ; a Bond splint 
w T ith compresses or two straight splints with compresses 
being the most satisfactory dressing to employ in this 
injury, the dressings being retained for three weeks. 

Fracture of the Carpal Bones. 

These fractures are usually compound or open fractures, 
and are so frequently associated with extensive laceration 
of the arm and hand that operative measures have to be 
resorted to ; but if such is not the case they are dressed, 
when compound, with an antiseptic dressing, and the hand 
and forearm are supported upon a well-padded palmar 



364 



FRACTURES. 



splint held in place by a roller bandage ; more or less im- 
pairment in the motion of the wrist is apt to follow these 
fractures. In simple fractures of the carpal bones the use 
of an evaporating lotion for a few days, in connection with 
the splint just mentioned, will be found useful. The 
dressings should be retained for three or four weeks, and 
after their removal passive motion should be employed to 
overcome as far as possible the joint-stiffness resulting. 

Fracture of the Metacarpal Bones. 

These fractures are often met with as the result of direct 
or indirect force applied to the metacarpal bones. The 

Fig. 261. 




Agnew's splint for fracture of the metacarpal bones. 

treatment of fractures of the metacarpal bones consists in 
first reducing the deformity, which is usually an angular 

Fig. 262. 




Dressing for fracture of the metacarpal bones. 



one, the projection of the angle being toward the back of 
the hand ; this is reduced by pressure with the fingers, 
and the hand and forearm should then be placed upon a 



FRACTURE OF THE PHALANGES. 



365 



palmar splint (Fig. 261) with a pad of oakum or cotton 
under the palm ; a compress of lint is next placed over the 
seat of fracture, and the hand and forearm are bound to 
the splint by the turns of a roller bandage. (Fig. 262.) 
At the end of three weeks union at the seat of fracture is 
usually quite firm, and the splint should be dispensed 
with at this time. 

Fractuee of the Phalanges. 

The treatment of fractures of the phalanges consists in 
reducing the displacement by extension and manipulation, 

Fig. 263. 




Gutta-percha splint for fracture of phalanx. (Hamilton.) 
Fig. 264. 




Dressing for fracture of phalanx with anterior and posterior splints. 

and in placing the finger in a moulded gutta-percha or 
pasteboard splint (Fig. 263), and securing the splint in 



366 FRACTURES. 

position by the turns of a roller bandage. When the 
proximal phalanx is fractured a narrow, padded, wooden 
splint extending from the end of the finger to the wrist 
should be applied upon the palmar surface of the finger and 
hand, and a short dorsal splint should also be used ; if there 
is a tendency to lateral displacement short lateral splints 
should also be employed, and the splints should be held in 
place by strips of plaster or by a roller bandage. (Fig. 264.) 
Union in fractures of the phalanges is usually quite firm 
at the end of three weeks, and the splints can be dispensed 
with at that time. 



Fractures of the Lower Extremity. 

Fkacture of the Femuk. 

Fractures of the upper extremity of the femur are those 
Involving the neck, great trochanter, and upper end of the 
shaft of the bone. 

In dressing fractures of the upper extremity of the femur 
the patient should be placed in bed upon a firm mattress, 
and an extension apparatus made from adhesive plaster 
should be applied to the leg, extending as far as the knee- 
joint. The extension apparatus is constructed by taking 
a piece of adhesive plaster two and a half inches in width 
and long enough to extend from the outer side of the knee 
to four inches below the sole of the foot, and from this 
point back to the inner side of the knee ; in the centre of 
this strip is placed a block of wood, two and a half inches 
wide and four inches in length, with a perforation in its 
centre ; the block and the inner surface of the strip on 
each side are next faced with a similar strip of adhesive 
plaster to a point about an inch above each malleolus ; a 
few straps are next wound around the wooden block to 
fix the previously applied straps ; the strip of plaster is 
next warmed and applied to the sides of the leg and held 
in position by three strips of adhesive plaster carried around 
the leg at intervals (Fig. 265), and the plaster is made 



FRACTURE OF THE FEMUR. 



367 



additionally secure by the application of a roller bandage 
applied to the foot and leg and carried up to the knee- 
Through the perforation in the block or stirrup is fastened 
a cord which passes over a pulley attached to the bed, 
and to this cord is attached the extending weight. The 
extension apparatus being applied, lateral support is given 
to the leg and thigh by sand-bags applied on either side ; 
the outer sand-bag should extend from the foot to the 



Fig. 265. 




Adhesive plaster extension apparatus applied to limb. (Ashhurst.) 

axilla, and the inner one from the foot to the groin. A 
weight of five or ten pounds is attached to the extending 
cord, and the lower feet of the bed should be raised on 
blocks a few inches high to prevent the patient from slip- 
ping down in bed ; a pad of oakum or cotton should also 
be placed under the tendo-Achillis to relieve the heel from 
pressure. This dressing is kept in place for from four to 
six weeks, and if union has occurred the patient is kept 
in bed for a few weeks longer and is then allowed to be 
about using crutches. In the majority of cases of fracture 
of the neck of the femur fibrous union only takes place, 
and after employing the dressing before described for six 
weeks the patient is allowed to get up and go about on 
crutches. It often happens that the subjects in whom 
these fractures occur are old and feeble, and if it is found 
that restraint in bed with the dressings here described is 
not well borne, under such circumstances they should be 



368 



FRACTURES. 



discarded and the patient should be allowed to sit up in 
bed with the limb resting on a pillow, or in a chair, the 
treatment of the local condition having to be disregarded, 
attention being given to the patient's constitutional con- 
dition. 



Fig. 266. 




Plaster- of-Paris bandage applied to thigh. (Hamii/i on. ) 



Fig. 267. 




^X 



a 



Smith's anterior splint for fracture of the femur. 



1 



The application of a plaster-of-Paris bandage to the leg, 
thigh, and pelvis is also sometimes made use of in the 



FRACTURE OF THE FEMUR. 



369 



treatment of fractures of the upper extremity of the 
femur; extension should be made from the foot while the 
bandage is being applied. (Fig. 266,) In fractures of 
the neck of the femur and of the upper part of the shaft 



Fig. 268. 




iirii;illiiiii.ii[|ll|]'\Hlllli|||!!li , ^ N ^ v — iNiilllllllllllll : 

Dressing for fracture of the femur with extension upon an inclined plane. 
(Agnew.) 

of the bone the anterior wire splint of Prof. N. R. Smith 
is sometimes used with advantage; the limb being swung 
from the splint the patient is able to move in bed without 
causing him pain or disturbing the fragments. (Fig. 267.) 
In fractures in the upper portion of the femur where there 

Fig. 269. 




Double inclined fracture-box. 



is marked tilting forward of the upper fragment Prof. 
Agnew employed extension made from the thigh and 
placed the limb upon a double inclined plane, maintaining 
this position during the treatment of the case. (Fig. 268.) 
With the same object in view, in place of the double in- 



370 FRACTURES. 

clined plane a double inclined fracture-box may be em- 
ployed, extension being made from the thigh by means of 
adhesive plaster strips applied above the knee, to which a 
weight is attached. (Fig. 268.) 

Fracture of the Shaft of the Femur. 

In the treatment of fractures of the shaft of the femur 
the dressings are applied to diminish as far as possible the 
shortening and to prevent angular or rotary displacement 
of the fragments. In dressing these fractures the patient 
should be placed upon a fracture-bed or an ordinary bed 
with a firm hair mattress ; an extension apparatus of ad- 
hesive plaster is applied and extension is made by a weight 
attached to this as previously described. Lateral support 
is given to the limb by the application of two wooden 
splints — the outer or long one extending from the axilla 
to the foot, the inner or short one extending from the groin 
to the foot. The splints at their upper extremity should 
be about six inches in width and at their lower extremity 
about three and a half inches. The splints are wrapped 
in a splint cloth which extends from the foot to the groin, 
and after this has been placed under the limb the splints 
are fixed in their proper positions, the short one to the 
inner side, the long one to the outer side of the limb. 
Between the limb and the splints are interposed bran- 
bags ; the outer bag should be long enough to extend from 
the axilla to the foot, the inner one from the groin to the 
foot. The splints and bran-bags are held in place by five 
or six strips of bandage passing under the limb and body 
and around the splints and bran-bags at intervals. The 
heel is saved from pressure by placing a wad of oakum or 
cotton under the tendo-Achillis, and after the splints have 
been brought into place the strips of bandage are firmly 
tied to secure them, and a weight of ten or twelve pounds 
is attached to the extending cord. The foot of the bed is 
raised to prevent the patient from slipping downward and 
to allow the weight of the body to act as a counter- extend- 
ing force. After the application of the dressings the thigh 



FRACTURE OF THE FEMUR. 



371 



should be slightly adducted. During the after-treatment 
of these fractures the surgeon should see that the splints 
and bran-bags are kept firmly in place and that the foot 
does not roll outward ; this is accomplished by untying 
the strips and readjusting the bags and then bringing up 
the splints and securing them in position by fastening the 
strips. (Fig. 270.) The extension apparatus usually does 
not require renewal during the course of treatment. The 
extension and splints are kept in place for four or six weeks, 
and at this time union at the seat of fracture is usually 
quite firm, so that they may be removed, and the fracture 
is then supported by moulded pasteboard splints or by the 



Fig. 270. 




Dressing for fracture of the shaft of the femur with lateral splints and bran-bags. 
(Ashhtjrst.) 

application of a plaster-of-Paris splint for several weeks 
longer, and at the end of eight weeks it is safe to allow 
the patient to be up and around on crutches. 

Many surgeons, in fracture of the shaft of the femur, 
prefer to use a long external sand-bag and a shorter in- 
ternal one in place of the corresponding long and short 
splints and bran-bags, and, if care is observed to see that 
the sand-bags are kept accurately in contact with the limb 
and body, excellent results may be obtained by this form 
of dressing. After considerable experience with both 
methods of furnishing lateral support in the dressing of 
fractures of the shaft of the femur, I am well satisfied 



372 FRACTURES. 

that angular deformity is less likely to result where the 
splints and bran-bags are employed. 

The plaster-of-Paris dressing, including the foot, leg, 
thigh, and pelvis, is employed by some surgeons in the 
early treatment of fracture of the shaft of the femur, the 
limb being kept well extended until the plaster has thor- 
oughly set. This dressing is applied in the ambulant 
method of treating fractures of the femur. The double 
inclined plane and the anterior angular wire splint are 
also sometimes employed in the dressing of fractures of 
the shaft of the femur. 

Fracture of the Shaft of the Femur in Children. 

The treatment of these fractures in young children by 
extension by a weight and pulley and lateral splints is 
often unsatisfactory on account of the difficulty in keeping 
the patient quiet upon his back, and from the soiling of 
the dressings by the feces and the urine. In children two 
years of age and over I have never found much trouble 
in employing extension and lateral support by splints and , 
bran-bags or sand-bags, and in these cases I make addi- 
tional fixation at the seat of fracture, and guard against 
displacement of the fragments by the child sitting up in 
bed when not watched, by carefully moulding external 
and internal pasteboard or felt splints to the thigh, and 
holding them in place by the turns of a bandage. I have 
employed this form of dressing even in children under 
two years of age with the most satisfactory results. 

In cases of fracture of the femur in children from a few 
months to a year or eighteen months of age, in whom it 
is difficult to obtain quietude, or who have to be moved to 
give them nourishment if they are taking the breast, the 
dressing which I have found most satisfactory consists in 
first applying a roller bandage from the foot to the groin, 
and then moulding to the outer half of the foot, leg, thigh, 
and also to half of the pelvis, a pasteboard or felt splint 
which is well padded with cotton, and held in position 
by the turns of a bandage carried from the foot to the 



FRACTURE OF THE FEMUR. 



373 



Fig. 271. 



pelvis and finished with circular turns about the pelvis. 
The splint should be so moulded as to include a little 
more than one-half of the circumference of the thigh and 
leg. If this splint becomes soiled it is easily replaced by 
a fresh one, and its removal and renewal are much easier 
than that of the plaster-of- Paris splint which is recom- 
mended by some surgeons in these cases. 

In young children fractures of the femur are often 
incomplete or green-stick fractures; and even when com- 
plete, the shortening is usually not marked, as the line of 
fracture is apt to be transverse, the periosteum often not 
being completely ruptured, which tends 
to hold the fragments in position. 

In green-stick fractures the deform- 
ity should be reduced by manipulation, 
even if it is necessary to convert the 
incomplete fracture into a complete one 
to accomplish this object. 

Mr. Bryant recommends that fract- 
ures of the femur in young children be 
treated in the vertical position; the 
injured limb, together with the sound 
one, is flexed at a right angle to the 
pelvis and fixed with a light splint, and 
attached to a cradle or bar abovefthe 
bed. (Fig. 271.) 

If the plaster-of-Paris dressing is 
used, the limb should be first enveloped 
from the foot to the pelvis with a flan- 
nel bandage, and extension should be 
made while the plaster-of-Paris bandage 
is being applied and should be kept up until the bandage 
has become fixed. The plaster bandage should extend 
from the toes to the pelvis, and it is well to fix the 
hip-joint by carrying several turns of the bandage about 
the pelvis. To prevent the splint from absorbing the 
discharges and becoming offensive, the upper portion of 
it may be coated with shellac. 

The time required for union in fractures of the femur 

17 




Fracture of the fe- 
mur treated by vertical 
extension. (Bryant.) 



374 FRACTURES. 

in children is about four weeks, and the dressings may 
be removed at this time, but the child should not be 
allowed to use the limb for several weeks after this period. 

Fracture of the Lower End of the Femur. 

The fractures met with in this portion of the femur are 
supra-condyloid fractures, or those in which one condyle 
is separated, or comminuted fractures in which both con- 
dyles are separated ; epiphyseal disjunctions of the lower 
end of the femur, met with in young subjects, may also 
be classed with fractures at this portion of the bone. 

The dressing of supra-condyloid fractures, if there is 
shortening, should be similar to that employed in fractures 
of the shaft of the femur, consisting in the application of 
an extension apparatus and bran-bags and splints or sand- 
bags to give lateral support ; if, however, there is no 
marked shortening the dressing employed should be the 
same as that applied in fractures involving one or both 
condyles or epiphyseal separations. 

The dressing employed in fracture of one or both con- 
dyles or in epiphyseal disjunction of the lower end of the 
femur consists in placing the limb in a long fracture-box 
extending from the foot to the upper third of the thigh, 
the box being well padded with a soft pillow, or a well- 
padded posterior splint, or a moulded pasteboard or felt 
gutter may be employed ; if either of these dressings is 
employed, the splint or gutter should be long enough to 
extend from the lower part of the leg to the upper part of 
the thigh. 

If there is much effusion into the joint or soft parts, 
lead-water and laudanum should be applied over the 
region of the injury for some days, until the swelling has 
subsided. At the end of two weeks it is well to place the 
limb in a plaster- of-Paris dressing extending from the 
foot to the upper part of the thigh. This dressing should 
be retained for four weeks, and at the end of this time the 
dressing should be removed, and if the union is suffi- 
ciently firm to allow the patient to go about on crutches, 



FRACTURE OF THE PATELLA. 375 

a fresh plaster-of-Paris splint should be applied extending 
from the middle of the leg to the middle of the thigh, or 
lateral splints of pasteboard may be substituted for the 
plaster dressing. 

A certain amount of permanent impairment of the joint 
motion is apt to follow fractures involving one condyle or 
both condyles of the femur. 

Feacture of the Patella. 

The dressing of fractures of the patella consists, first, 
in the application of a roller bandage from the toes to the 
upper part of the leg; a well-padded posterior wooden 
splint long enough to extend from the middle of the leg 
to the middle of the thigh, or an Agnew splint, which is 
provided with pegs for the attachment of strips of adhe- 
sive plaster (Fig. 272) is next placed under the limb. A 

Fig. 272. 




Agnew' s splint for fracture of the patella. 

small compress of lint is next placed above the upper 
fragment, and a similar compress is placed below the lower 
fragment ; a strip of adhesive plaster one and a half inches 
in width and twenty- four inches in length has its middle 
portion applied over the compress, and its ends are then 
brought obliquely downward and fastened to the splint, 
or to the pegs if Agnew's splint be used ; this may be re- 
inforced by a second or third strip. The object of these 
strips is to bring the upper fragment down in contact with 
the lower fragment. A strip of plaster with the ends 
passing in the opposite direction is next placed over the 



376 



FRACTURES. 



lower compress, and the ends are fastened to the splint or 
pegs ; this strip serves only to steady the lower fragment, 
as it cannot be drawn upward to meet the upper fragment 
by reason of the inextensibility of its ligamentous attach- 
ment. (Fig. 273.) If the Agnew splint is employed the 
strips of plaster may be tightened by turning the pegs to 
which they are fastened without removing the splint. 

Fig. 273. 




*fck... f.lnliu.u;. 



\3MMMhihk 



iin.lillk.juim:.. J 



Agnew 's splint applied. 

The splint is next firmly fixed in contact with the limb 
by the turns of a roller bandage extending from the lower 
to the upper end of the splint. The limb should next be 
placed upon an inclined plane or in a long fracture-box 
with its foot elevated to relax the quadriceps femoris 
muscle. This dressing should be removed and reapplied 
in a few days, as the dressings become loose as the swelling 
about the seat of injury subsides, and after this disappears 
the dressings require renewal at less frequent intervals, and 
usually at the end of three weeks the splint may be re- 
moved and a plaster-of-Paris bandage may be applied 
extending from the middle of the leg to the middle of the 
thigh. At the end of six weeks the patient may be allowed 
to walk upon the limb, the knee-joint being fixed with a 
plaster-of-Paris or pasteboard splint. 

It is well, after the removal of the splints, for the 
patient to wear for some months a laced muslin knee- 
supporter, which gives some support to the knee-joint. 

The union in fractures of the patella is usually fibrous, 
although in rare cases bony union has occurred. 



FRACTURE OF THE BONES OF THE LEG. 377 

A great variety of splints have been devised and used 
in the treatment of fractures of the patella, the main object 
of which is to fix the knee-joint and bring the fragments 
as nearly as possible in apposition. Malgaigne's hooks or 
Levis's modification of the same are employed by some 
surgeons to secure close apposition of the fragments. The 
method of treatment in fractures of the patella, which con- 
sists in exposing the fragments by an incision, and drilling 
and suturing them with catgut or silver wire sutures, is also 
employed at the present time, the strictest antiseptic pre- 
cautions being taken to prevent infection of the wound. 

In cases of rupture of the fibrous union after fracture 
of the patella, which is not an uncommon accident, the 
treatment of the case should be the same as that for a 
recent fracture of the patella. 



Fracture of the Bones of the Leg. 

In fractures of both bones of the leg the displacement is 
usually very marked ; when one bone only is broken, the 
sound bone, acting as a splint, prevents much deformity, 

Fig. 274. 




Fracture-box with movable sides. 



except in case of fracture at the lower end of the fibula, 
when the foot inclines to the injured side. 

The dressing for fractures of both bones of the leg or 
for fracture of the tibia or fibula alone, except in cases 
where the lower portion of the fibula is the seat of injury, 
is best accomplished by the use of a fracture-box. (Fig. 
274.) The displacement being overcome as far as possible 
by extension and manipulation, the leg is placed in a 
fracture-box, which is prepared for the reception of the 



378 



FRACTURES 



limb by having the sides let down and having a soft pillow 
laid in it ; the foot is next secured to the footboard by a 
loop of bandage passed around the foot, the ends being 
tied after passing through the slots in the footboard ; a 
pad of oakum or cotton is placed under the tendo Achillis 
to relieve the heel from pressure, and a similar pad is 
placed between the sole of the foot and the footboard. 
(Fig. 275.) The sides of the box are then brought up and 
secured by two or three strips of bandage tied around the 
box. In Vising a fracture-box in the treatment of fractures 
of the bones of the leg, the surgeon should see that the foot 



Fig. 275. 




Application of the fracture-box. 



is kept well down to the footboard and is at a right angle 
with the leg, that there is no eversion of the knee, and 
that the pillow is full enough to make equable pressure 
upon the leg when the sides of the box are secured, and 
that the heel is not subjected to undue pressure — the use 
of a pad of oakum or cotton under the tendo Achillis being 
employed to prevent this complication. Where there is a 
tendency to tilting upward of the lower end of the upper 
fragment the lower fragment can be brought in line with 
this by raising the foot by a mass of oakum or cotton 
placed under the tendo Achillis and heel, and so overcom- 
ing the deformity. In some cases division of the tendo 



FRACTURE OF THE BONES OF THE LEG. 379 

Achillis may be required before this deformity can be 
corrected. 

The subsequent dressings of the case are conducted by 
letting down the sides of the box and correcting any dis- 
placement, if present, by adjusting the limb and pads in 
their proper position, and again bringing up the sides of 
the box and securing them. At the end of two weeks the 
fracture-box may be removed and a plaster-of-Paris dress- 
ing may be applied to the limb, which will allow the patient 
more freedom of movement in bed, or permit of his sitting 
up without disturbing the fragments (Fig. 276). 



Fig. 276. 



4 



r~ ■ ■ 




Plaster bandage applied to fracture of the leg. 

Union in fractures of the bones of the leg is usually 
quite firm in six weeks, but the patient should not be 
allowed to put his weight upon the limb in walking for 
at least eight weeks. 

If the patient is restless, and finds his position with the 
fracture-box resting upon the bed irksome, the fracture- 
box may be swung from a frame fastened over the bed 
(Fig. 277). _ 

The application of a plaster-of-Paris dressing as a 
primary dressing — the ordinary plaster of-Paris bandage 
or the Bavarian dressings being applied — in fractures of 
the bones of the leg, is adopted by some surgeons, and, if 
employed, the case should be under constant supervision 



380 



FRACTURES. 



for a few days, so that the dressing can be removed if a 
dangerous amount of swelling takes place. Moulded 
splints of felt or pasteboard are also sometimes applied in 
the treatment of these cases. (Fig. 278.) 



Fig. 277. 




Fracture-box suspended. (Agnew.) 

The ambulant method of treatment of fractures of the 
bones of the leg and femur, which has recently been in- 
troduced, consists in applying a plaster-of-Paris bandage 
in case of fracture of bones of the leg from the toes to 
the middle of the thigh. The region of the ankle should 
be well padded with cotton, and the plaster bandage should 
be applied so as to form a very firm, thick dressing over the 



FRAC1TJRE OF THE BONES OF THE LEG, 



381 



foot, ankle, and lower part of the leg ; the region of the 
knee should also be well padded. When employed for frac- 
tures of the femur the bandage should be applied in the 
same manner, but it should be carried high enough to 
obtain points of support upon the pelvis, at the tuberosity 
of the ischium and outer surface of the ilium, these parts 



Fig. 278. 




Moulded binder' s-board splints for fracture of the leg. 

being well padded and the turns of the bandage being 
carried around the pelvis. In the ambulant method ot 
treatment, the patient, as soon as the bandage has become 
firm, is allowed to walk about, first with crutches or a cane, 
and finally bearing his weight upon the injured limb. 

In patients suffering with delirium tremens, or in 
maniacal patients, the use of a fracture-box in the treat- 
ment of fractures of the bones of the leg is often not 



382 FRACTURES. 

satisfactory on account of the difficulty in restraining the 
movements of the patient and the consequent displace- 
ment of the fragments. In such cases it is well to apply 
a few strips of binder's-board, well padded with cotton, 
to the limb, extending above and below the seat of the 
fracture, holding them in place by a few turns of a roller, 
and then to wrap the limb and foot in a soft pillow, and 
hold this in place by the turns of a roller bandage applied 
with moderate firmness. This dressing allows the patient 
to move the limb without serious disturbance of the frag- 
ments, and, after the patient recovers from his attack, the 
leg may be placed in the fracture-box or in a plaster-of- 
Paris dressing. 

In fractures of the bones of the leg in young children 
the same difficulty is often experienced in keeping them 
quiet, and for this reason a fracture-box cannot be used 
with satisfaction. In dressing these cases, two lateral 
splints of pasteboard, moulded to the foot and leg and 
well padded with cotton, may often be employed with the 
best results. The splints should not be wide enough to 
meet on the anterior or posterior surface of the leg or foot. 
The splints, after being carefully adjusted, are held in 
place by the turns of a roller bandage ; and, after these 
splints have been applied for two weeks, and all swelling 
has subsided at the seat of fracture, a plaster-of- Paris 
bandage may be substituted for them, which should be 
worn for three weeks ; at the expiration of this time union 
is usually firm enough to dispense with all dressings. 



Fkactuee of the Fibula. 

In fractures of the fibula, with the exception of that 
fracture occurring at the lower end of the bone, the de- 
formity is not marked, and they are usually dressed with 
a fracture-box applied as in the dressing of fractures of 
both bones of the leg, and at the end of two weeks a 
plaster-of-Paris dressing should be applied, and the patient 
may be allowed to get out of bed and move about on 



FRACTURE OF THE FIBULA. 383 

crutches. The union in a fracture of the fibula is usually 
quite firm at the end of five weeks, and all dressings may 
be dispensed with at that time. 

Fracture of the Lower End of the Fibula. 

This fracture usually occurs in the lower fifth of the 
bone, and is often associated with a laceration of the in- 
ternal lateral ligament of the ankle-joint or a sprain-frac- 
ture of the internal malleolus, and is usually accompanied 
by marked eversion of the foot. This fracture is com- 
monly known as Pott's fracture. 

In this fracture, after reducing the displacement by ex- 
tension and manipulation, the limb should be placed in a 
fracture-box provided with a soft pillow, the foot should 
be secured to the footboard, and a pad of oakum or cotton 
should be placed under the tendo Achillis ; before bring- 
ing up the sides of the box and securing them two firm 
compresses of lint or oakum should be placed in contact 
with the leg, one just above the inner malleolus, the other 
just below the outer malleolus. The sides of the box are 
next brought up and secured, and by the pressure of these 
compresses the foot is brought into an inverted position 
and the deformity is corrected. 

The after-dressing of this fracture consists in letting 
down the sides of the box, and in inspecting the parts to 
see that the foot is kept in the proper position, and care 
should be taken to see that undue pressure is not made 
upon the skin by the compresses, which might result in 
ulceration ; this may be avoided by sponging the skin 
with alcohol and changing the positions of the compresses 
slightly at each dressing. At the expiration of ten days 
the fracture-box and compresses may be removed and the 
limb maybe put up in a plaster-of-Paris dressing, including 
the foot and leg up to the knee. The patient may then 
be allowed to go about on crutches, and at the end of five 
weeks all dressings may be dispensed with. A certain 
amount of stiffness and even permanent impairment in 
the motion of the ankle-joint often results from these 



384 



FRACTURES. 



fractures. This fracture is also dressed by means ot 
Dupuy trends splint, which consists of a straight wooden 
splint long enough to extend from the condyles of the 
femur to the end of the toes ; this splint is provided with 
padding, the thickest part of which, several inches in 
thickness, should rest upon the skin just above the inner 
malleolus when the splint is applied to the inner side of 
the leg. The splint is applied to the inner surface of the 
leg with the thickest part of the pad resting upon the skin 
just above the inner malleolus, and is secured in position 
by the turns of a roller applied over the foot and at the 
upper part of the leg. (Fig. 279.) After using this dress- 

FlG. 279. 




Dupuytren's splint applied. 

ing for a few days if the displacement is satisfactorily 
corrected the splint may be removed and the leg may be 
placed in a fracture-box or in a plaster-of-Paris dressing. 
This splint, when applied with sufficient firmness to 
correct the displacement, is not, as a rule, a comfortable 
dressing to the patient, so that in practice the use of the 
fracture-box and compresses will be found a more com- 
fortable dressing and one equally satisfactory in correcting 
the deformity. 



Fractures of the Bones of the Foot. 

Fracture of the Tarsal Bones. 

The calcaneum and astragalus are the tarsal bones most 
frequently fractured. The dressing of fractures of the 
calcaneum after reducing the displacement, which is not 



FRACTURE OF THE TARSAL BONES. 



385 



usually marked unless the posterior portion of the bone 
is involved by manipulation, consists in placing the leg 
and foot in a fracture-box, and care should be taken to 
see that the foot is kept at a right angle to the leg. When 
the fracture involves the posterior portion of the bone 
and there is displacement by the action of the muscles 
inserted into the fragment, the leg should be flexed upon 
the thigh and the foot should be extended ; this position 
may be maintained by applying a well-padded curved 
splint to the anterior portion of the leg and foot and 
securing it in position by a bandage, or the same result 
may be obtained by applying a band or padded collar 
around the thigh, which is made fast by a cord or strap to 
the heel of a slipper applied to the foot. (Fig. 280.) 

Fig. 280. 




Apparatus for fracture of posterior portion of the calcaneum. (Hamilton.) 



Fractures of the astragalus, after reducing any deform- 
ity which is present by extension and manipulation, are 
dressed by placing the foot and leg in a fracture-box, care 
being taken to see that the foot is kept at a right angle to 
the leg. This precaution is important, as ankylosis not 
infrequently occurs after this fracture, and if the foot is in 
the proper position it is much more useful to the patient. 

As soon as the swelling, which is usually very marked 
after fracture of the calcaneum or astragalus, subsides, the 
foot and leg should be put up in a plaster-of-Paris ban- 



386 FRACTURES. 

dage. The amount of tension and the inability to reduce 
the displacement in cases of fracture of the astragalus may 
be indications for excision of the fractured bone. The 
time required for union in fractures of the tarsal bones is 
from five to six weeks. 



Fracture of the Metatarsal Bones. 

These fractures are dressed by placing the foot upon a 
well-padded plantar splint, and using compresses to hold 
the fragments in place if there is much displacement, the 
splint and compresses being held in position by a bandage ; 
or they may be treated by placing the foot and leg in a 
fracture- box, the footboard of the box acting as a plantar 
splint ; the plaster-of-Paris dressing may also be used in 
these cases. The time required for union in fracture ot 
the metatarsal bones is from three to four weeks. 



Fracture of the Phalanges of the Toes. 

These fractures are often compound and attended with 
so much laceration of the soft parts that immediate ampu- 
tation is required ; when, however, the fractures are sim- 
ple, or in compound fractures where amputation is not 
required, the dressing consists in applying a plantar splint 
of wood or binder' s-board, extending beyond the toes and 
securing it in position by the turns of a roller bandage. 
When a single toe only is broken a moulded splint of 
gutta-percha or binder's-board may be applied, and a 
portion of the splint should extend some distance upon 
the sole of the foot, to fix the proximal joint and also to 
give it a firm point of fixation ; the moulded splint should 
be held in position by a narrow roller bandage or by 
strips of adhesive plaster. The time required for union 
in fractures of the phalanges of the toes is about three 
weeks. 



DRESSING OF COMPOUND OB OPES FRACTURES 387 



Dressing of Compound or Open Fractures. 



In the dressing of compound or open fractures the same 
dressings and splints which are generally used in the 
treatment of simple or closed fractures may be employed : 
the wound in the soft parts requires a special dressing and 
this should be so arranged as to secure free drainage and 
promote its prompt healing. In some cases of compound 
fracture the treatment of the injuries of the soft parts de- 
mands attention first, and in such cases the injury to the 
bones is for a time disregarded, care being taken to see 
that the fragments are kept quiet, so as to prevent further 
damage to the soft parts until the wound is in such a 
condition that the proper manipulation to reduce the dis- 
placement and fix the fragments by splints and suitable 
dressings can be undertaken without interfering with the 
repair of the wound. 



Fig. 251. 




Method of reducing a compound fracture. (Ha^jiltox.) 

In the dressing of compound or open fractures the skin 
surrounding the wound should be first carefully cleansed 
and the wound should next be thoroughly irrigated with 
a 1 : 2000 bichloride solution or a 1 : 40 carbolic solution. 
and any foreign bodies or loose fragments of bone should 
be removed, and if there is hemorrhage it should be con- 
trolled by securing the bleeding vessels with ligatures. 
The reduction of the displacement should next be accom- 



388 FRACTURES. 

plished by making extension and by manipulation (Fig. 
281); if the fragments project from the wound, before this 
can be satisfactorily accomplished it may be necessary to 
enlarge the wound and to resect one or both ends of the 
fractured bones, and in some cases it may be necessary to 
drill the ends of the fragments and introduce a strong 
wire or catgut suture, or a metallic nail or screw, to hold 
them in their proper positions. After reduction of the 
displacement the wound should again be thoroughly irri- 
gated with the antiseptic solution, and after making pro- 
vision for drainage by the introduction of a drainage-tube 
or tubes, counter-openings being made to secure free drain- 
age if necessary, the dressings should be applied. 

The wound, if a small one, need not be closed with 
sutures; but if extensive, a few catgut, silk, or silkworm- 
gut sutures may be applied to bring the edges of the wound 
into apposition, care being taken to avoid making undue 
tension ; if the soft parts have been much lacerated or con- 
tused, it is better to introduce no sutures. A final irriga- 
tion of the wound through the drainage-tube is next made, 
and the wound is covered by a piece of protective, and the 
ordinary gauze dressing should be applied and covered 
by a number of layers of bichloride cotton, the whole 
dressing being held in position by a gauze bandage applied 
with moderate firmness. 

The reduction of the fragments and the dressing of the 
wound having been accomplished as has been described, 
the splints and dressings appropriate for a similar fracture, 
if it were a simple or closed one, are next applied. If the 
surgeon has been able to render the wound aseptic, and 
has applied an antiseptic dressing, the compound fracture 
is often soon converted into a simple one, by the prompt 
healing of the wound, and the patient may exhibit no 
more constitutional disturbance than he would have with 
a similar simple or closed fracture. The re-dressing of a 
compound fracture dressed in this way need not be made 
for a week or ten days, unless there is a rise in the patient's 
temperature or the dressings become soaked with dis- 
charges from the wound, or they become uncomfortable to 



DRESSING OF COMPOUND OR OPEN FRACTURES. 389 

the patient by reason of swelling of the soft parts in the 
region of the wound. When the re-dressing of the frac- 
ture becomes necessary, the dressings are removed, and 
the drainage-tubes may be removed if no longer needed ; 
the wound being re-dressed with an antiseptic dressing, 
the splints are reapplied, and, after the wound is healed, 
the subsequent dressing of the fracture should be the same 
as that of a simple fracture. The time required for union 
in a compound fracture is usually much longer than in a 
corresponding simple fracture. 

Many ingenious splints have been devised for the dress- 
ing of special compound fractures, but these were princi- 
pally used before the introduction of the antiseptic method 
of wound-treatment, and as the treatment of these cases 
has been much simplified by its use, they possess no special 
advantage over the ordinary splints and dressings used in 
simple fractures. 

Fig. 282. 




Fenestrated plaster dressing for compound fracture of the leg. (Stimson.) 

The plaster- of -Par is dressing may be used as a primary 
dressing in compound fractures ; the displacement being 
reduced and the wound being dressed with an antiseptic 
gauze dressing, a plaster-of- Paris bandage is applied to the 
parts so as to firmly fix the fragments ; the joints on either 
side of the fracture should be fixed by the bandage, and 
the parts should be held in position until the plaster has 



390 FRACTURES. 

set firmly After the plaster has become firm, a fenestrum 
should be made over the position of the wound, so that it 
can be inspected or dressed through this when necessary. 
The ends of a piece of stout wire, bent into a semicircle, 
may be incorporated in the turns of the plaster bandage 
above and below the position of the fenestrum, to give it 
additional strength after the removal of a portion of the 
bandage to make the fenestrum. (Fig. 282.) 

If the plaster-of-Paris dressing is applied as a primary 
dressing in compound fractures the case should be care- 
fully watched for a few days, and if much swelling occurs 
at the seat of fracture its removal and renewal are indicated ; 
profuse discharge of serum may also soak the dressings 
and bandage so that its renewal is necessitated. Some 
surgeons, therefore, prefer to defer the application of the 
plaster-of-Paris dressing in compound fractures for a few 
weeks until the swelling has diminished and the wound is 
nearly or quite healed ; the wound being covered with an 
antiseptic dressing the plaster bandage is applied and a 
fenestrum is made over the position of the wound if 
required. 

Binder' s-board or felt splints may also be employed in 
the dressing of compound fractures, being moulded to the 
parts after an antiseptic dressing has been applied to the 
wound, and held in position by the turns of a roller 
bandage. 

The principal advantage in the use of these splints is 
the ease with which they can be removed and reapplied if 
frequent dressings of the fracture are necessary for any 
reason. They may be used during the course of treatment, 
or, after a few weeks when the swelling has diminished at 
the seat of fracture and the wound is well advanced toward 
repair, they may be discarded and a plaster-of-Paris dress- 
ing substituted. In compound fractures of the bones of 
the leg, after reducing the displacement and applying an 
antiseptic dressing to the wound, I usually apply moulded 
binderVboard splints to either side of the leg, including 
the foot, and place the leg in a fracture-box for additional 



DRESSING OF COMPOUND OB OPEN FRACTURES. 391 

security, and after a few weeks I discard the binder's- 
board splints and apply a plaster of- Paris dressing. 

Bran dressing for compound fractures was formerly a 
popular dressing in this city, especially for compound 
fractures of the leg and thigh. It was applied by placing 
a piece of muslin or rubber cloth over the bottom and 
sides of a fracture-box, and upon this was placed a layer 
of bran ; the fractured leg was next placed in the box 
upon the layer of bran, the foot was then fastened to the 
footboard, and the sides of the box were brought up and 
secured ; bran was next poured into the box and firmly 
packed around and over the limb. The bran absorbed the 
discharges which escaped from the wound, and at the sub- 
sequent dressings the soiled bran was renewed without 
disturbing the limb, and fresh bran was packed about the 
limb. 

Sawdust which has been saturated with a solution of 
bichloride of mercury and dried may be used in the same 
manner as bran in the dressing of compound fractures, and 
the former, which has been rendered antiseptic, has decided 
advantages over the bran dressing. 

Continuous irrigation of compound fractures by a warm 
antiseptic solution either of bichloride of mercury 1 : 4000 
or of carbolic acid 1 : 60, in cases in which so much contu- 
sion or laceration of the soft parts exists that the applica- 
tion of the ordinary dressings would be attended with the 
risk of gangrene, will be found a most satisfactory method 
of treatment. This dressing is applied by supporting the 
injured extremity upon a splint laid on a pillow covered 
by a rubber cloth, and a can or jar with a nozzle contain- 
ing the solution is placed over the part, and the irrigation 
is accomplished by allowing the fluid to run continuously 
over the wound ; this irrigation may be kept up for days 
or weeks, and when the vitality of the parts is assured an 
antiseptic dressing with the ordinary splints or a plaster- 
of- Paris bandage may be applied. 

A method of dressing compound fractures which has 
recently been introduced consists in rendering the skin in 



392 FRACTURES. 

the region of the wound aseptic and removing any foreign 
bodies from the wound, then rendering it as far as possible 
aseptic; iodoform is then dusted thickly over the wound 
at intervals and, mixing with the blood and serum from 
the wound, is allowed to dry, forming an antiseptic scab, 
the wound being exposed to the air, and the fragments are 
retained in position by splints or by a fracture-box. 



PAET IT. 

DISLOCATIONS. 



A dislocation is the displacement of the articular sur- 
faces of bones which enter into the formation of a joint. 

Dislocations may be complete, partial, simple, compound, 
and complicated, and they are also known as recent and old 
dislocations, the latter terms being used not entirely with 
reference to the length of time the displacement of the 
articular surfaces of the bones has existed. 

A complete dislocation is one in which no portions of the 
articular surfaces of the bones remain in contact with each 
other. 

A partial dislocation is one in which portions of the 
articular surfaces of the bones still remain in contact with 
each other. 

A simple dislocation is one in which there exists dis- 
placement in the relation of the articular surfaces of the 
bones with little injury to the soft parts adjacent to the 
joint, and the displaced ends of the bones do not com- 
municate with the air by a wound in the soft parts. 

A compound dislocation is one in which there exists dis- 
placement of the articular surfaces of the bones which 
communicate with the air through a wound in the soft 
parts. 

A complicated dislocation is one in which, in addition to 
the displacement of the articular surfaces of the bones, 
there exists a fracture, or a laceration of important blood- 
vessels, nerves, or muscles in proximity to the dislocation. 



394 DISLOCATIONS. 

A recent dislocation is one in which the displacement of 
the articulating surfaces of the bones has existed for such 
a period that time has not been afforded for inflammatory 
changes to take place in the articular surfaces of the bones 
or in the adjacent tissues which would seriously inter- 
fere with their reduction. 

An old dislocation is one in which the displacement of 
the articulating surfaces of the bones has existed for some 
time, and in this variety of dislocation the displaced bones 
often form firm adhesions to the surrounding tissues. 

Treatment of Dislocations. 

The first indication in the treatment of dislocations is to 
return the displaced articular surfaces of the bones to their 
normal position and to retain them in this position by the 
use of suitable dressings. The return of the articular sur- 
faces of the bones to their normal position or the reduction 
of the dislocation is accomplished by manipulation, exten- 
sion, and counter-extension. The reduction of dislocations 
should be attempted as soon as possible after they have 
occurred. 

The principal obstacles to the reduction of dislocations 
are muscular resistance and the anatomical peculiarities of 
the joints. The former is best overcome by the use of an 
anaesthetic given to the point where complete muscular 
relaxation is produced. The resistance offered by the 
changed relations of the articular surfaces and the liga- 
ments is to be overcome by the surgeon making such 
manipulations, founded upon his knowledge of the anatomy 
of the parts, as will make the ligaments, muscles, and 
bones assist in the reduction of the dislocation. 

In recent dislocations by the use of extension and ma- 
nipulation, especially if an anesthetic be employed, the 
reduction is usually accomplished without the use of much 
force ; but in old dislocations, where absolute muscular 
shortening has taken place, the use of extending bands is 
often required, and in securing these bands to the limb 
the clove-hitch knot is useful. (Fig. 283.) 



DISLOCATIONS OF THE VERTEBRAE. 395 

The treatment of dislocations after reduction consists in 
placing the joint at complete rest by the application of 
suitable splints and bandages, and in treating any inflam- 
matory complications if they arise, by the application of 

Fig. 283. 



Clove-hitch knot applied. (Erichsen ) 



evaporating lotions, and in a week or two after the injured 
ligaments have been repaired passive motion should be 
resorted to for restoring the function of the joint. 



Special Dislocations. 

Dislocations of the Vertebra. 

Dislocations of the lumbar and dorsal vertebrce, as simple 
dislocations, are extremely rare accidents ; they are occa- 
sionally met with , but are more often associated with frac- 
tures of the vertebrae in these regions ; their occurrence in 
the cervical vertebrae is more common. The treatment of 
dislocations of the vertebrae, whether complicated w T ith 
fracture or not, consists in attempting reduction by mak- 
ing extension and counter-extension with manipulation, 
and by this means in many cases the luxations can be 
reduced. Jf, however, the efforts at reduction are unsuc- 
cessful, permanent extension should be applied by means 
of a weight-extension apparatus from both legs and from 
the shoulders and head. The after-treatment consists in 



396 



DISLOCATIONS. 



keeping the patient at rest upon his back in bed upon a 
firm mattress, and if the cervical vertebrae have been in- 
volved the head and neck should be supported by short 
sand-bags, and in case of the vertebrae below this point, 
the application of a plaster-of-Paris jacket may be used to 
give support and fixation to the parts. The general man- 
agement of the case as regards complications is similar to 
that in cases of fracture of the vertebrae. 

Dislocations of the coccyx are reduced by manipulations 
with the finger in the rectum and external manipulation 
at the same time. The only after-treatment required is 
rest in bed for a few days and the administration of 
opium to keep the bowels quiet. 

Dislocation of the Jaw. 

This dislocation may consist in the displacement of one 
or both condyles of the jaw from the glenoid fossae, consti- 



FlG. 284. 




Bilateral dislocation of the jaw. (Ashhurst.) 



DISLOCATION OF THE JAW. 



397 



tutiug the unilateral or bilateral dislocation of the jaw ; 
the latter is the more common form of dislocation of the 
jaw met with, and the deformity resulting is shown in 
Fig. 284. 

The reduction of a dislocation of the lower jaw is accom- 
plished as follows : The surgeon placing his thumbs, well 
protected by strips of bandage or a towel, on the molar 
teeth or behind them, presses the angles of the jaw down- 
ward while he elevates the chin with his fingers, and by 
this manipulation the condyles of the jaw usually slip 

Fig. 285. 




Method of reducing dislocation of the lower jaw. (Hamilton.) 

back into place with a snap. After reduction of the dis- 
location the jaw should be fixed for a week or ten days 
by the application of a Barton's bandage or a four-tailed 
sling. (Fig. 285.) 

Dislocation of the Hyoid Bone. 

A few cases of dislocations of the hyoid bone have been 
recorded ; the treatment consists in throwing back the 
head as far as possible, to place the muscles of the neck 
upon the stretch, depressing the lower jaw and pressing 
the luxated bone into position. 



18 



398 DISLOCATIONS. 

Dislocation of the Ribs. 

The ribs may be dislocated at their vertebral articula- 
tions or at the junction with their costal cartilages. The 
treatment of these dislocations consists in reducing the 
displacements by manipulation and pressure and then in 
fixing the chest to secure immobility of the ribs by strap- 
ping the affected side with strips of adhesive plaster, the 
same dressing being applied as in cases of fracture of the 
ribs, the dressing being retained for three or four weeks. 

Dislocation of the Sternum. 

Dislocation or diastasis of the sternum may occur at the 
junction of the manubrium and gladiolus or at the junc- 
tion of the ensiform cartilage and gladiolus. The reduc- 
tion is effected by extension of the chest by bending the 
dorsal spine over a firm cushion placed under the back 
and by pressure upon the projecting bone ; when the dis- 
placed bone has been reduced a compress should be placed 
over the seat of injury, and held in place by broad strips 
of adhesive plaster, or by a bandage to keep the parts at 
rest. The dressing should be retained for three or four 
weeks. 

In the few examples of dislocations of the ensiform 
cartilage which have been reported, the displacement of 
the cartilage has in some cases given rise to persistent 
vomiting, which was relieved by reduction of the displace- 
ment ; it is, however, almost impossible to keep the frag- 
ment in place after reduction, and the vomiting gradually 
disappears after a time in those cases where it is impos- 
sible to keep the cartilage in its normal position. 

Dislocation of the Pelvis. 

Dislocations or diastasis of the bones of the pelvis may 
occur at the pubic or sacro-iliac symphyses. 

These are generally serious injuries, as they are apt to 
be complicated by lesions of the pelvic viscera. 



DISLOCATIONS OF THE CLAVICLE. 



399 



The reduction of these dislocations is effected by pressure 
and manipulation, and after reduction the parts should be 
supported by a compress held in place by a stout binder 
or by broad strips of adhesive plaster, the patient being 
kept quiet in bed, and the pelvis being supported by 
means of sand-bags. The dressings should be retained 
for from four to six weeks. 



Dislocations of the Clavicle. 

Dislocations of the clavicle may occur either at the 
sternal or acromial end, and the latter injury some writers 
describe as a dislocation of the scapula, following the gen- 
eral rule that the distal bone is the one dislocated. 

Dislocations of the sternal end of the clavicle may occur 
in a forward, backward, or upward direction, and the dis- 
placement is generally well marked. (Fig. 286.) The 

Fig. 286. 





Dislocation of sternal end of clavicle 
forward. (Bryant.) 



Dislocation of clavicle at acromial 
end. (Bryant.) 



reduction of this dislocation is effected by placing the 
knee against the spine, and drawing the shoulders outward 
and backward and pressing the displaced end of the 
clavicle into place. The reduction is generally easy, but 
it is often difficult to keep the end of the bone in its 
proper position. To accomplish this, a compress should 



400 DISLOCATIONS. 

be placed over the end of the bone, and this should be 
secured in place by broad strips of adhesive plaster ; the 
shoulders should be brought well backward and secured 
by a posterior figure-of-eight bandage of the chest, and the 
arm of the injured side should be fastened to the sid^ of 
the chest by spiral turns of a bandage. In some cases, in 
addition to the compress over the end of the bone, secur- 
ing the arm of the injured side in the Velpeau position 
will be found all that is necessary to retain the bone in 
position. 

Dislocation of the acromial end of the clavicle may be 
upward, downward, or backward. (Fig. 287.) The re- 
duction is effected by manipulation of the arm and scapula 
and by pressure over the displaced end of the clavicle. 
The displacement is usually reduced without much trouble, 
but it is often a matter of difficulty to keep the end of the 
bone in its proper place. 

The dressing consists in placing a compress over the 
acromial end of the clavicle and holding it in place by 
broad strips of adhesive plaster ; the arm should at the 
same time be fixed in the Velpeau position. These dress- 
ings after reduction of dislocations of the clavicle should 
be kept in place for at least three weeks. Although in 
many cases a certain amount of deformity persists, the 
disability resulting from the injury is not often marked. 

Dislocations of the Scapula. 

Dislocation of the acromion process of the scapula from 
the outer end of the clavicle, which has been described 
under dislocation of the acromial end of the clavicle, is 
classed by some writers as a scapular dislocation. 

Dislocation or projection of the inferior angle of the 
scapula , due to its escape from under the latissimus dorsi 
muscle or relaxation of this muscle and of the serratus 
magnus, is sometimes described as a dislocation of the in- 
ferior angle of the scapula. The reduction of this deformity 
consists in the employment of manipulation and pressure 
to overcome the displacement, and the use of a compress 



DISLOCATIONS OF THE SHOULDER. 



401 



held in place by broad strips of adhesive plaster to secure 
the bone in its proper position. 



Dislocations of the Shoulder. 

The head of the humerus may be dislocated downward, 
forward, or backward. 

Subglenoid or downward dislocation of the head of the 
humerus is that variety of dislocation in which the head 
of the bone rests in the axilla. (Fig. 288.) 



FIG. 288. 




Subglenoid dislocation of the shoulder. (Stimson.) 

Subcoracoid or forward dislocation of the head of the 
humerus is that variety of dislocation in which the head 



402 



DISLOCATIONS. 



of the humerus rests beneath the coracoid process of the 
scapula. ((Fig. 289.) 

/Subclavicular dislocation of the head of the humerus may 
be considered an aggravated form of the latter variety of 
dislocation ; the head of the humerus in this variety of 
dislocation rests beneath the clavicle. 

Fig. 289. 




Subcoracoid dislocation of the shoulder. (Stimson.) 

Subspinous or backward dislocation of the head of the 
humerus is that variety of dislocation in which the head 
of the humerus rests beneath the spine of the scapula. 
(Fig. 290.) 

The reduction of dislocations of the humerus is effected 
by manipulation, by extension and counter-extension, and 
by a combination of these methods. 

Manipulation in the reduction of subglenoid dislocation 



DISLOCATIONS OF THE SHOULDER. 



403 



of the humerus is practised by first flexing the forearm 

upou the arm to relax the long head of the biceps muscle; 

the elbow is next seized and abducted so as to bring it to 

the side of the patient's head, thus relaxing the deltoid 

and supra spinous muscles ; the surgeon or an assistant 

next places his hand upon 

the head of the humerus FlG - m 

in the axilla, and, as the 

arm is drawn outward to 

a right angle with the 

body by the other hand, 

he pushes the head of 

the bone into the glenoid 

cavity. 

In the reduction of sub- 
glenoid and subclavicular 
dislocations the manipula- 
tions are the same except 
that the arm is to be ro- 
tated outward before being 
carried downward. 

In the reduction of sub- 
spinous dislocations after 
the arm has been abducted 
it should be rotated inward 
and direct pressure should be made upon the head of the 
bone as the arm is adducted. Reduction may also be 
effected by extension and counter- extension as in Cooper's 
method, where extension is made from the arm downward 
and counter-extension is made by the heel in the axilla. 
(Fig. 291.) 




Subspinous dislocation of the head of the 
humerus. (Erichsen.) 



Kocher's Method of reduction of dislocations of the 
shoulder consists in flexing the elbow at a right angle and 
pressing it closely against the side, the forearm at the same 
time being turned as far as possible away from the trunk. 
While the external rotation is being maintained the elbow 
is carried well forward and upward and the arm is rotated 
inward and the elbow is lowered. 



404 



DISLOCATIONS. 



Reduction may also be accomplished by extension made 
upward, as in Mothers method, the scapula being fixed 



Fig. 291. 




Reduction of shoulder by heel in the axilla. (Erichsen.) 
Fig. 292. 




Reduction of shoulder by extension upward. 



by the foot or hand placed over the acromion process. 
(Fig. 292.) 



DISLOCATIONS OF THE ELBOW. 405 

After reduction of dislocations of the head of the 
humerus the arm should be bound to the side of the body 
by the turns of a spiral bandage of the chest, or should 
be held against the side by the application of a Velpeau 
bandage (Fig. 59, p. 68) ; this dressing should be removed 
at intervals of a few days, and after ten days or two weeks 
all dressings should be dispensed with, passive motion 
should be employed, and the patient allowed to move the 
arm. 

Dislocations of the Elbow. 

Dislocation of the Bones of the Forearm. 

Dislocations of the bones of the forearm at the elbow 
may either be backward, forward, or lateral. The back- 
ward dislocation is the most common form. (Fig. 293.) 

Fig. 293. 




Dislocation of "both bones of the forearm backward. (Liston.) 

The reduction of backward dislocations is effected by 
making traction upon the forearm and at the same time 
making pressure upon the lower end of the humerus as 
the forearm is flexed upon the arm. 

Or the reduction may be accomplished by bending the 
arm slowly and forcibly over the knee placed upon the 
inner surface of the elbow so as to press upon the radius and 
ulna, separating them from the humerus and freeing the 
coronoid process from its abnormal position. (Fig. 294.) 

Lateral dislocations of the bones of the forearm at the 
elbow are reduced by making extension from the forearm, 

18* 



406 



DISLOCATIONS, 



and at the same time making direct pressure on the dis- 
placed bones and counter-pressure on the lower end of the 
humerus. 



Fig. 294. 




Reduction with the knee in the bend of the elbow. (Hamilton.) 



Forward dislocations of the bones of the forearm at the 
elbow are reduced by making forced flexion at the elbow, 
together with extension or counter-extension, or by mak- 
ing forced extension of the forearm at the elbow, pressing 
the humerus backward and suddenly flexing the forearm. 

The dressing, after the reduction of dislocations at the 
elbow, consists in the application of a well-padded anterior 
right- or slightly obtuse-angled splint, to keep the forearm 
in a flexed position — the dressing being practically the 
same as that for fractures of the lower end of the humerus, 
with an anterior angular splint (Fig. 295). This dressing 



DISLOCATION OF THE RADIUS. 407 

should be retained for two or three weeks, being removed 
at intervals of several days ; after the removal of the splint, 

Fig. 295. 




Dressing after reduction of dislocation of the elbow. 

passive motion should be practised, to prevent stiffness of 
the elbow r -joint. 

Dislocation of the Head of the Radius. 

The head of the radius may be displaced forward, out- 
ward, or backward, the forward dislocation being the most 
frequent. (Fig. 296.) The reduction of these disloca- 
tions is effected by making extension from the forearm 
and counter-extension from the lower end of the humerus, 
and at the same time the head of the bone is pressed into 
its proper position. The dressing after reduction of the 
displacement consists in the application of a compress over 
the head of the bone, and the arm and forearm should 
be placed upon a well-padded anterior angular splint, 
which is secured by a roller bandage. The dressing is 
similar to that employed in fractures of the lower end of 
the humerus, in which an anterior angular splint is em- 
ployed (Fig. 251, page 354). Difficulty is sometimes ex- 
perienced in keeping the head of the bone in position after 
reduction, so that the use of the compress in addition to 
the use of the splint is often required. The arm should 



408 



DISLOCATIONS. 



be kept upon the splint for three weeks, being re-dressed 
at intervals. 



Fig. 296. 




Dislocation of head of the radius forward. (Liston.) 



Dislocation of the Upper End of the Ulna. 



The upper end of the ulna may be displaced backward, 
the olecranon projecting beyond the condyles of the 
humerus, while the head of the radius occupies its normal 
position. The reduction of this displacement is effected 
in the same manner as that of both bones of the forearm 
backward, and the dressing after reduction is similar to 
that employed when both bones have been displaced. 



DISLOCATIOXS OF THE WRIST. 



409 



Dislocations of the Wrist. 

The lower end of the ulna may be dislocated from the 
radius forward, backward, or inward. The reduction of 
these displacements is effected by fixing the radius and 
pushing the ulna back into place. The dressing after 
reduction consists in placing the wrist-joint at rest by the 
application of well-padded anterior and posterior straight 
splints. The splints should be retained for three or four 
weeks, dressings being made at intervals of two or three 
days. 

Dislocations of the carpus upon the bones of the forearm 
may be forward (Fig. 297), or backward (Fig. 298). The 



Fig. 297. 



Fig. 298. 





Dislocation of the carpus forward. 
(Hamilton.) 



Dislocation of the carpus backward. 
(Hamilton.) 



reduction in either variety of displacement is effected by 
extension from the hand and by pressure. After reduc- 
tion of the displacement, which does not tend to recur, 
the hand and the forearm should be placed upon a well- 
padded straight splint applied to the palmar surface of the 
hand and forearm. The splint should be retained for ten 
days or two weeks. 



410 DISLOCATIONS. 



Dislocations of the Bones of the Carpus. 

The displacement of the individual bones of the carpus 
occasionally takes place, the os magnum, the semilunar and 
pisiform being the bones most usually displaced, although 
other bones of the carpus are sometimes dislocated. Re- 
duction is effected by means of extension and pressure, 
and the part should afterward be dressed with a palmar 
splint and compresses. 



Dislocations of the Metacarpal Bones. 

The metacarpal bones may be dislocated upon the 
carpus ; the bones most commonly displaced are those of 
the thumb and of the index and middle fingers ; the latter 
are usually displaced backward, while the metacarpal bone 
of the thumb may go either backward or forward. 

Reduction is effected by extension and pressure. The 
dressing after reduction consists in the application of a 
palmar splint to the hand and forearm and a compress 
over the displaced bone. The dressings should be retained 
for two weeks. 



Dislocations of the Fingers. 

Dislocations of the phalanges of the fingers usually take 
place at the metacarpophalangeal junction, but sometimes 
occur at the inter-phalangeal joints. The reduction is 
usually easily effected by extension (Fig. 299), or by push- 
ing the phalanx back until it stands perpendicularly upon 
the metacarpal bone, when by strong pressure upon its 
base, from behind forward, it is readily carried by flexion 
into its natural position. 

Where difficulty is experienced in making extension in 
the reduction of these dislocations, the ingenious apparatus 
of the late Dr. Levis (Fig. 300), or the " Indian puzzle " 
apparatus (Fig. 301), may be employed with success. 



DISLOCATIONS OF THE FINGERS. 



411 



In dislocations of the proximal phalanx of the thumb 
backward (Fig. 302), great difficulty in reduction is often 



Fig. 299. 




Backward dislocation of phalanx. Reduction by extension. (Hamilton.) 

experienced from the head of the metacarpal bone slipping 
between the two heads of the short .flexor muscle, or 

Fig. 300. 




Levis's apparatus for dislocation of the phalanges applied. 

between the lateral ligaments. The interposition of the 
external sesamoid bone is considered by some surgeons 

Fig. 301. 




Extension by Indian puzzle. (Bryant.) 

to be the cause of difficulty in the reduction of this dis- 
placement. 

In this dislocation reduction is effected by firmly press- 
ing the metacarpal bone of the thumb strongly toward the 
palm of the hand to relax the two portions of the short 
flexor muscle. The thumb is next extended upon the 



412 



DISLOCATIONS. 



wrist until its tip points to the elbow. An assistant now 
places his finger behind the proximal phalanx to prevent 
its slipping backward, and by bringing the thumb down 
to the flexed position the bone slips into place. It some- 
times happens that all efforts at reduction fail, and in such 
cases it may be necessary to divide one head of the short 
flexor muscle subcutaneously or through an open wound 
before the displacement can be relieved. 



Fig. 302. 




Dislocation of proximal phalanx of thumb backward. (Farabeuf.) 

The dressing of dislocations of the phalanges after re- 
duction consists in the application of splints of wood, or 
moulded splints of binder's-board, or gutta-percha, to fix 
the joint, which should be retained for ten days or two 
weeks. 

Dislocations of the Hip. 

The head of the femur is most frequently dislocated 
backward, downward, or upward, although it may assume 
other positions in exceptional cases. 

Posterior or backward dislocations of the head of the 
femur are either backward and upward, when they are 
described as iliac or dorsal, the bone resting upon the dor- 
sum of the ilium (Fig. 303) ; or the dislocation may be 
backward, the head of the bone resting upon the ischiatic 
notch ; these are known as ischiatic dislocations, or dislo- 



DISLOCATIONS OF THE HIP. 



413 



cations of the femur dorsal below the tendon (of the ob- 
turator interims), according to Bigelow (Fig. 304). 

The reduction of the posterior dislocations of the femur 
can generally be effected by manipulation. The patient 



Fig. 303. 



Fig. 304. 





Backward and upward dislo- 
cation of femur. (Cooper.) 



Backward dislocation of femur. 
(Cooper.) 



being anaesthetized and placed upon his back, the surgeon 
grasps the leg at the ankle and knee, flexes the leg upon 
the thigh, and the thigh upon the pelvis ; he then abducts 
the limb and rotates it outward, bringing it in a broad 
sweep across the abdomen, and by bringing it down to its 
natural position the head of the bone will slip into the 
acetabulum. (Fig. 305.) 

Downward Dislocation of the Head of the Femur, or 



414 



DISLOCATIONS. 



Downward and Forward Dislocation. — In this variety of 
dislocation the head of the bone rests upon the thyroid fora- 



Fig. 305. 



Fig. 306. 





Downward and forward dislocation 
of femur. (Cooper.) 



Reduction of backward dislocation of 
femur. (Bigelow.) 

men ; this form of displace- 
ment is sometimes spoken of 
as a thyroid dislocation. (Fig. 
306.) 

The reduction of downward 
and forward dislocations of 
the head of the femur is ef- 
fected by flexing the leg and 
thigh and bringing the limb 
into a position of abduction ; it is then adducted and ro- 
tated inward in a broad sweep across the abdomen and 
brought down to its natural position, and the head of the 
bone slips into the acetabulum. (Fig. 307.) 

In making these manipulations the head of the bone 
sometimes slips back upon the dorsum of the ilium, con- 
verting the downward dislocation into a posterior one ; if 
this accident occurs the displacement should be remedied 
by making the manipulations appropriate for the reduction 
of the latter dislocation. 



DISLOCATIONS OF THE HIP. 



415 



Upward Dislocation, or the Dislocation Forward and 
Upward, of the Head of the Femur. — In this variety of 




Fig. 308. 




Reduction of downward and forward dis- 
location of the femur. (Bigelow.) 

dislocation the head of the bones 
rest upon the pubis ; this form of 
displacement is also spoken of as 
a pubic dislocation. (Fig. 308.) 
The reduction of forward and 
upward dislocations of the head 
of the femur is effected by much 
the same manipulation as is em- 
ployed in the reduction of down- For ward and upward dislocation 

ward and forw r ard dislocations, of the femur. (Cooper.) 
except that in the pubic disloca- 
tion the flexed limb should be carried across the sound 
thigh at a higher point. The thigh being flexed the head 
of the bone is drawn down from the pubis ; it is then semi- 
abducted and rotated inward to disengage the bone com- 
pletely. While rotating inward and drawing on the thigh 
the knee should be carried inward and downward to its 
place by the side of its fellow, and the head of the bone 
w r ill usually slip into the acetabulum. 

As before stated various anomalous displacements of the 



416 



DISLOCATIONS. 



Fig. 



head of the femur occasionally occur ; the head of the bone 
may pass directly upward, or downward between the sciatic 
notch and thyroid foramen, or downward and backward 
on the body of the ischium, or downward and backward 
into the lesser sciatic notch, or downward, inward, and 
forward into the perineum. These anomalous displace- 
ments usually occur where there has been extensive lacera- 
tion of the capsular and Y-ligaments. 

The dressing of cases, after reduction of dislocations of 
the head of the femur, consists in keeping the patient at 

rest in bed upon his back, and 
the limb should be kept at rest 
by sand-bags applied to either 
side of the limb, or the knees 
should be tied together. 

The patient should be kept 
at rest for two or three weeks, 
and at the end of this time may 
be allowed to get out of bed 
and go about on crutches. 

Dislocations of the 
Patella. 

The patella may be dislocated 
outward, inward, or upward, or 
it may be rotated upon its own 
axis. The outward dislocation 
is the displacement most usually 
seen. (Fig. 309.) 

Upward dislocation of the 
patella can only result from 
laceration of the ligamentum 
patellae, and the treatment in 
such cases is similar to that for fracture of the patella. 

The reduction of dislocations of the patella is effected 
by extending the leg upon the thigh, and flexing the thigh 
upon the pelvis to relax the quadriceps femoris muscle, 
when the patella can usually be forced back into place ; in 




Outward dislocation of the 
patella. (Duplay.) 



DISLOCATIONS OF THE KNEE. 417 

some cases alternate flexion and extension of the leg will 
accomplish the same result. 

The dressing after reduction of the displacement con- 
sists in the application of a posterior straight splint or 
a moulded binderVboard or felt splint to keep the joint 
at rest; the splint should be worn for a week or ten days. 

Dislocations of the Knee. 

The head of the tibia may be dislocated forward, back- 
ward, or laterally ; the latter dislocations are always incom- 
plete, forward dislocation being the variety of displacement 
most commonly met with. (Fig. 310.) 

The reduction of dislocations of the knee is effected by 
extension and counter-extension with forced flexion of the 




External condyle of femur 
Forward dislocation of the knee. (Bryant.) 

knee with pressure, aided by rocking movements. The 
treatment of cases of dislocation of the knee after reduc- 
tion consists in fixing the knee-joint by the application of 
a straight posterior splint or a moulded splint of binder's- 
board. As there is usually marked swelling following 
these injuries from violence to the joint-structures, the 
application of evaporating lotions for a few days will be 
found useful. As soon as the swelling has subsided the 
joint should be put up in a plaster-of- Paris dressing, and 
this should be retained for four weeks. 



418 DISLOCATIONS. 

Dislocation of the Semilunar Cartilages. 

The displacement here consists in the slipping forward 
or backward and wedging of the semilunar cartilages be- 
tween the femoral condyles and the tibia. 

Reduction of the displaced cartilages can usually be 
effected by hyper-flexion of the knee followed by sudden 
full extension, or by alternately flexing and extending the 
joint. Excision of the displaced cartilages is sometimes 
required in cases in which they cannot be reduced by 
manipulation. 

The dressing of these cases after reduction of the dis- 
placed cartilages consists in the application of a posterior 
straight splint or a plaster-of- Paris dressing to fix the 
knee-joint ; the splint should be worn for three or four 
weeks, and if there is a tendency to redisplacement the 
patient should wear a knee-cap of leather or muslin to 
partially fix the joint, with compresses so arranged as to 
make pressure upon the edge of the joint. 

Dislocation of the Fibula. 

Dislocations of the fibula may occur at either of its ex- 
tremities, and the direction of the displacement may be 
forward, backward, or upward, dislocation of the head or 
upper extremity of the fibula being the most common, 
although all are rare forms of displacement. 

The reduction of dislocations of the head of the fibula 
is effected by flexing the leg upon the thigh and making 
direct pressure and extension. Dislocations of the lower 
extremity of the fibula are reduced by manipulation and 
pressure. The dressing of cases after reduction of dislo- 
cations of the fibula consists in the application of a com- 
press and moulded binder's-board splint, and the dressing 
should be retained for three or four weeks. 

Dislocations of the Ankle. 

Dislocation of the foot upon the bones of the leg 
results from the separation of the articular surface of the 



DISLOCATIONS OF THE TARSAL BONES. 



419 



astragalus from that of the tibia and fibula, and the dis- 
placement may he forward, backward (Fig. 311), or lateral 
(Fig. 312), the latter variety being often associated with 
fractures of the malleoli. 



Fig. 311. 



Fig. 312. 





Dislocation of foot backward. 
(Bryant.) 



Dislocation of foot inward. 
(Bryant.) 



The reduction of dislocations of the ankle is effected by 
traction, combined with flexion and rotation of the ankle- 
joint, the leg being first flexed upon the thigh to relax the 
tendo Achillis, and in some cases the subcutaneous divi- 
sion of this tendon is required before the reduction can be 
satisfactorily accomplished. 

The dressing of dislocations of the ankle after reduction 
consists in the application of a fracture-box, or of paste- 
board splints to fix the ankle, care being taken to see that 
the foot is fixed at a right angle to the leg, and in the 
application of evaporating lotions for a few days ; after 
the swelling has subsided a plaster-of-Paris dressing 
should be applied and retained for three or four weeks. 

Dislocations of the Tarsal Bones. 

The astragalus may be dislocated from the bones of the 
leg and from the other tarsal bones, being thrust for ward, 



420 



DISLOCATIONS. 



Fig. 313. 



backward, outward (Fig. 313), or inward. The reduction 
of dislocations of the astragalus outward is effected by first 
flexing the leg upon the thigh and making extension from 
the foot and rotating it at the same time, direct pressure 
being made upon the displaced bone; in some cases subcu- 
taneous section of the tendo Achillis has assisted materially 
in the reduction of the displaced bone. Backward dislo- 
cation of the astragalus is usually irreducible ; the patient, 
however, in many cases recovers with a useful foot. In 
cases of irreducible dislocations of the astragalus, excision 
of the astragalus may ultimately be required. 

After the reduction of dislocations of the astragalus, 
the foot and leg should be put at rest in a fracture-box, 
or by means of moulded splints of pasteboard or felt ; 
evaporating lotions should also be employed to the region 

of the injury for a few days, 
and when the swelling has 
subsided, a plaster - of- Paris 
dressing should be applied 
and retained for three or four 
weeks. 

Dislocations of the calca- 
neum and scaphoid upon the 
astragalus, or of the calca- 
neum upon the astragalus and 
cuboid, or upon the astragalus 
alone ; of the scaphoid and 
cuboid upon the calcis and 
astragalus ; or of the cuboid, 
scaphoid, or cuneiform bones, 
are occasionally met with. 

Their reduction is effected 
by traction and direct pres- 
sure, and after this has been 
accomplished the parts should 
be put at rest by the appli- 
_ . ,. ' . , . cation of a splint and com- 

Dislocation of astragalus outward. * 

(Hamilton.) presses. 




OLD DISLOCATIONS. 



421 



Dislocations of the Metatarsal Bones and 
Phalanges of the Toes. 

These dislocations usually result from crushing forces 
which destroy the vitality of the soft parts so completely 
that amputation is required. Their reduction in cases of 
simple or uncomplicated dislocations is effected by trac- 
tion, manipulation, and pressure. After reduction of the 
displacement, the parts should be kept in position by the 
application of splints and compresses. 

Old Dislocations. 

The reduction of old dislocations is attended with more 
difficulty and danger than that of recent dislocations, due 
to the permanent contraction and structural changes which 
occur in the muscles, and to the abnormal adhesions 



Fig. 314. 




Reduction of old dislocation of the femur by pulleys. (Cooper.) 

which form between the displaced bone and the parts 
with which it is in contact. The reduction of old dis- 
locations can usually be accomplished by the manipula- 
tions appropriate for recent dislocations of the same va- 
riety, but occasionally the use of more forcible extension is 
required, which is made by bands and pulleys (Fig. 314), 

19 



422 



DISLOCATIONS. 



or by vertical extension (Fig. 315). The first step in the 
reduction of old dislocations consists in thoroughly break- 
ing up the adhesions which have been formed between the 
displaced bone and the surrounding tissues ; this has, in 
some cases, resulted in the laceration of muscles, nerves, 
and bloodvessels, and in the fracture of the displaced bones 

Fig. 315. 




Reduction of old dislocation of hip by vertical, extension. (Bigelow.) 



or neighboring bones, so that the manipulations should be 
made w T ith the least force that will accomplish the object 
desired. After the reduction of old dislocations, difficulty 
is sometimes experienced in maintaining the bone in its 
proper place, due to the changes which have occurred in 
the articular surfaces. 



CONGENITAL DISLOCATIONS. 423 

Compound Dislocations. 

These are always grave injuries, and amputation or 
excision is often required. When, however, operative 
measures are not required, the reduction is effected in the 
same manner as in simple dislocations of corresponding 
parts, the greatest care being taken to render the wound 
aseptic, and to keep it in this condition by the application 
of a full antiseptic dressing. 

Complicated Dislocations. 

In dislocations complicated by fracture near the seat of 
displacement, the displaced bone should, if possible, be 
first reduced, and this in many cases is a matter of much 
difficulty, as the fracture prevents the surgeon from using 
leverage otherwise present, in the reduction, and he has 
often to depend entirely upon pressure and manipulation 
to restore the displacement. 

After reduction of the dislocation the fracture should be 
reduced and dressed. 

Dislocation complicated by rupture of the main artery 
of the limb may require, after reduction of the displace- 
ment, exposure and ligation of the vessel or amputation 
of the limb. Rupture of an important nerve trunk com- 
plicating a dislocation may call for subsequent exposure 
and suturing of the divided nerve. 

Spontaneous Pathological and Congenital 
Dislocations. 

In the treatment of these varieties of dislocations after 
the reduction of the displacement by manipulation and 
pressure, much difficulty is often experienced in maintain- 
ing the reduction. To effect the latter object the use of 
splints and bandages is employed, and also the use of 
many ingenious forms of apparatus adapted to particular 
dislocations. 

Tenotomy or myotomy is often required to prevent 
recurrence of the deformity, and continuous extension is 
also of much value in the treatment of these displacements. 



PART V. 

OPERATIONS 



In view of the fact that at the present time in our 
medical schools much more attention is paid to practical 
surgery, that is, operative procedures upon the cadaver, 
it has been thought advisable to introduce a very brief 
description of a number of operations which can with 
advantage be performed upon the cadaver. Too much 
value cannot be attached to the importance of the student 
rendering himself familiar with the use of instruments 
and their manipulation in the various operative pro- 
cedures, and also familiarizing himself with the appear- 
ance of the anatomical parts exposed in operations. The 
introduction of sutures, the application of ligatures, the 
closing of wounds, the cutting and fitting of flaps in 
plastic operations, are procedures, the practical value of 
which, to the student, cannot be overestimated. 



Ligation of Arteries, 

In the application of a ligature to an artery in its con- 
tinuity the surgeon should make his incision in the line 
which corresponds to the general course of the vessel, and 
he should be thoroughly familiar with the anatomy and 
with the surgical landmarks of the part. A portion of 
the vessel, when possible, should be selected for the appli- 
cation of the ligature half an inch or an inch from any 



LIGATION OF ARTERIES. 



425 



large collateral branch. The position of the incision being 
selected, the surgeon steadies the skin with two fingers and 
makes an incision of the required length through it with 
a scalpel; the superficial fascia is next picked up on a 
director, any large superficial veins which come into view 
being displaced and divided to an equal length with the 
incision in the skin ; the deep fascia being exposed, it 
should be nicked and divided upon a director ; the inter- 
muscular space or the edge of the muscle or muscles 
which are the guide to the vessel should next be sought 



Fig. 316. 



Fig. 317. 





Opening sheath. Passing ligature aroand the 
vessel. Tying the artery. (Bryant.) 



Aneurism needle. 



for, small vessels coming from the main vessel through 
these spaces will often serve as valuable guides to the 
position of the vessel. The surgeon next separates the 
tissues with the director, handle of the knife, or the finger 
until the sheath of the vessel is exposed ; this is recognized 
by its communicated pulsation and by the absence of the 
smooth shining surface and pinkish-white color which 



426 OPERATIONS. 

the surface of the artery presents. The sheath of the 
artery should be picked up with forceps and nicked with 
the point of the knife applied flatwise ; the incision into 
the sheath should be very limited, only large enough to 
allow the aneurism needle to pass through it around the 
vessel ; extensive dissections or separations of the sheath 
from the vessel should be avoided, as the nutrition of the 
artery at the point of ligature may thus be impaired and 
sloughing and secondary hemorrhage may result. A dis- 
tinct sheath is found only about the main arterial trunks, 
which is replaced in the smaller arteries by a layer of 
loose cellular tissue. The wall of the artery being exposed 
an aneurism needle is passed around the vessel, threaded 
with a catgut ligature, and withdrawn ; the needle may be 
threaded before being passed, in which case the ligature 
is grasped with forceps and drawn through while the 
needle is withdrawn. The best material for ligatures is 
carefully prepared chromicized catgut. The needle should 
be passed away from important structures such as accom- 
panying veins and nerves. 

Before the ligature is tied the surgeon should satisfy 
himself that the ligature when tied will control the circu- 
lation in the vessel below its point of application, by 
placing the tip of his finger upon the vessel and drawing 
upon the ends of the ligature so as to occlude the vessel at 
the point of application. Being satisfied as to this point, 
the ligature is tied with a reef-knot, or a surgeon's knot 
and reef-knot combined. 

Some authorities recommend the application of two 
ligatures a short distance apart in the ligation of vessels 
in their continuity, and a division of the vessel between 
them, so that both ends can retract into the cellular sheath. 

The ends of the ligature are cut short in the wound, 
which is irrigated and drained if necessary, and is closed 
by the application of a few sutures, and an antiseptic 
dressing is applied. 



LIGATION OF THE INNOMINATE ARTERY. 427 

Ligation of Special Arteries. 

Ligation of the Innominate Arteky. 

The innominate artery lies immediately behind the 
sterno-clavicular articulation, and is in relation in front 
with the innominate veins and pneumogastric nerve, on 
the inner side with the trachea, on the outer side and be- 
hind with the pleura. 

Incision. — A V-shaped incision, each branch of which 
is two and a half or three inches in length, one of which 

Fig. 318. 




Line of incision for— A, innominate artery ; B, right subclavian artery ; C, left 
subclavian artery ; Z>, vertebral or inferior thyroid artery ; E, axillary artery 
below clavicle. (Stimson.) 

lies over the anterior edge of the sterno-cleido-mastoid 
muscle, and the other parallel to and a little above the 
clavicle. (Fig. 318, A.) The incisions are carried down 
to the superficial fascia and a flap is dissected up. If the 
anterior jugular vein is met with, it should be displaced. 
The sternal and clavicular attachments of the sterno- 
cleido-mastoid are next divided upon a director half an 
inch above the bone. The sterno-thyroid and sterno- 
hyoid muscles and the middle cervical fascia are next ex- 



428 OPERATIONS. 

posed, covered by the thyroid veins. The outer fibres of 
the sternohyoid and sterno-thyroid muscles are next 
divided, the thyroid vein being held aside, when upon 
tearing through the fascia with a director the common 
carotid artery is exposed and traced down to the innomi- 
nate artery ; the in Dominate veins are pressed against the 
sternum with the finger, and the artery is separated from 
its sheath about half an inch below its bifurcation, and 
the aneurism needle is passed around the vessel from the 
outer side so as to avoid the vein, pneumogastric nerve, 
and pleura. 

Ligation of the Subclavian Artery. 

This artery may be tied at three points ; in its first 
portion, between the trachea and scaleni muscles ; in its 
second portion, behind the scaleni muscles ; and in its third 
portion, external to the scaleni muscles. 

The left subclavian artery in its first portion is larger 
and more vertical in its direction than the right subclavian, 
and is situated more posteriorly ; from the difficulty in 
exposing this portion, and from the possibility of injuring 
the thoracic duct, the ligation of this artery in its first 
portion has been seldom attempted. 

Incision for the first portion of the subclavian artery is 
the same as that for the innominate (Fig. 318,-4), and the 
ligature is passed from the outer side, the pneumogastric 
and phrenic nerves being pressed inward toward the 
carotid artery. 

The right and left subclavian arteries are also seldom 
tied in their second portions — that is, behind the scaleni 
muscles ; but are frequently tied in their third portions — 
that is, external to the scaleni muscles. 

Incision for the second portion of the subclavian artery 
begins an inch external to the sternoclavicular articulation 
half an inch above and parallel to the clavicle, and is three 
or four inches in length. (Fig. 318, B or 01) The steps 
of the operation are the same as for ligation of the third 
portion, and when the scalenus anticus muscle has been 



LIGATION OF THE INNOMINATE ARTERY. 429 



exposed it is divided upon a director; the phrenic nerve 
which lies upon its anterior aspect is to be avoided. 

Incision for the third portion of the subclavian artery is 
the same as for the second portion. (Fig. 318, B or C.) 



Fig. 319. 




Ligation of subclavian and lingual arteries. (Bey ant.) 

The skin and platysma being divided, the jugular vein is 
exposed and drawn to one side or divided between the 
ligatures ; the superficial fascia is next divided upon a 
director ; the posterior belly of the omo-hyoid muscle is 
next found and drawn upward and outward ; the outer 
border of the scalenus anticus is next felt for and followed 
down to the tubercle of the first rib — the artery lies 
against this, between it and the lowest bundle of the 

19* 



430 OPERATIONS. 

brachial plexus. The artery is next denuded with the 
director, and the needle is passed from below, care being 
taken not to include the lowest bundle of the brachial 
plexus in the ligature. (Fig. 819.) 

Ligation of the Vertebral Artery. 

Incision for the ligation of the vertebral artery is three 
or three and a half inches in length, parallel with the 
anterior edge of the sterno-cleido-mastoid muscle, ending 
an inch above the clavicle. (Fig. 318, D.) The anterior 
edge of the sterno-cleido-mastoid being exposed the middle 
cervical fascia is divided and the carotid artery and jugu- 
lar vein are exposed and drawn inward. The gap between 
the longus colli muscle and the scalenus anticus muscles is 
next felt for about an inch below the carotid tubercle; the 
fascia covering it is next torn through and the muscles are 
separated and the vertebral vein comes into view. When 
this vein is held aside the vertebral artery is exposed, 
and the ligature is then passed around it. 

Ligation of the Inferior Thyroid Artery. 

Incision for the inferior thyroid artery is the same as 
that for the vertebral artery. (Fig. 318, D.) The anterior 
edge of the sterno-cleido-mastoid muscle being exposed it 
is drawn outward, the middle cervical fascia is next divided, 
and the carotid artery and internal jugular vein are drawn 
outward with a retractor. The head being flexed slightly, 
the surgeon feels for the carotid tubercle, and then sepa- 
rates the cellular tissue with a director, and the artery 
should be found below the carotid tubercle. The needle 
should be passed between the artery and vein. 

Ligation of the Internal Mammary Artery. 

Incision , a vertical one, two and a half inches in length, 
commencing at the lower border of the clavicle, parallel 
with and three lines external to the margin of the sternum. 



LIGATION OF THE COMMON CAROTID ARTERY. 431 

Divide the skin and superficial fascia and expose the fibres 
of the great pectoral muscle, the external intercostal apon- 
eurosis and the muscular fibres of the internal intercostal 
muscle. Raise the fasciculi of the latter muscle upon a 
director and divide them, and the vessels will be exposed. 
The internal mammary artery is not often tied below 
the fourth intercostal space. 

Ligation of the Common Carotid Artery. 

The point of election for the ligation of the common 
carotid artery is just above the omo-hyoid muscle, about 



Fig. 320. 




Line of incision for common carotid artery at point of election. (Stimson.) 

three-quarters of an inch below the bifurcation of the 
vessel, which takes places at a point on a line with the 
upper border of the thyroid cartilage. 

Incision for the common carotid artery is three inches 
in length along the anterior border of the sternocleido- 
mastoid muscle, the centre of which corresponds with the 
crico-thyroid space. (Fig. 320.) 

Divide the skin, platysma, cellular tissue and apo- 



432 



OPERATIONS. 



neurosis, avoiding the superficial veins, and expose the 
anterior edge of the sterno-cleido-niastoid ; seek for the 
interspace between this muscle and the sterno-hyoid and 
sterno-thyroid muscles, draw the latter muscles inward 
and the artery will be exposed with the jugular vein 
external to it ; the descendens noni nerve lying upon its 
sheath, which should be displaced outward. The sheath 
is next picked up and opened and the artery is separated 




Relation of the left common carotid artery above the omo-hyoid muscle. 

(ESMARCH.) 



from it with a director ; the artery lies internally, the in- 
ternal jugular vein externally and somewhat more super- 
ficial, and the pneumogastric nerve lies between the two 
and is more deeply placed. The sympathetic nerve is 
posterior to the vessel external to the sheath. The needle 
is passed from without inward, care being taken to avoid 
injury of the vein and nerve. (Fig. 321.) 



LIGATION OF THE INTERNAL CAROTID ARTERY. 433 



Ligation of the External Carotid Artery. 

Incision for the ligation of the external carotid artery 
is over the inner edge of the sterno-cleido-mastoid muscle 
from the angle of the jaw to a point corresponding to the 
middle of the thyroid cartilage. (Fig. 322, B.) The skin, 
platvsrua, and cellular tissue being divided, the external 
jugular vein is drawn aside when encountered; the deep 
fascia being opened, the facial and lingual veins will be 
exposed, which should be drawn to one side; the artery is 
next exposed covered by the hypoglossal nerve and the 
stylo-hyoid and digastric muscles. The vessel should 
next be isolated from the internal carotid artery and in- 
ternal jugular vein, both of which lie along its outer side. 
The needle should be passed from without inward. 



Ligation of the Internal Carotid Artery. 

Incision the same as for the external carotid artery (Fig. 
322, B) ; the vessel is external to the external carotid 

Fig. 322. 




Line of incision for— A. Lingual artery. B. External and internal carotid arteries. 
C. Occipital artery. D. Temporal artery. E. Facial artery. (Stimson.) 



434 OPERATIONS. 

artery, and in passing the needle the point should be 
directed away from the internal jugular vein — that is, 
from without inward. 

Ligation of the Superior Thyroid Artery. 

Incision about three inches in length along the anterior 
border of the sterno-cleido-mastoid muscle, starting a little 
lower down than that for the external carotid artery. The 
skin, superficial fascia, platysma, and deep fascia being 
divided, the cellular tissue in the sulcus between the upper 
portion of the larynx and the great vessels of the neck 
should be broken up with the director and the vessel 
exposed. The needle should be passed around the vessel 
from above downward. 

Ligation of the Lingual Artery. 

Incision a, curved one two inches long, its concavity 
directed upward from the anterior edge of the sterno- 

FlG. 323. 




Relations of the lingual artery. (Esmarch.) 

cleido-mastoid muscle half an inch above the great horn 
of the hyoid bone, to a point one inch within the median 



LIGATION OF TEE OCCIPITAL ARTERY. 435 

line of the neck. (Fig. 322, A.) Divide the skin and 
platysrna, displacing the superficial veins, and open the 
deep fascia, when the submaxillary gland will be exposed; 
this is displaced upward with the handle of the knife and 
the tendon of the digastric muscle attached to the hyoid 
bone, and the hypoglossal nerve will be exposed; next 
divide the fibres of the hypoglossus muscle midway be- 
tween the hypoglossal nerve and the hyoid bone, and the 
lingual artery will be exposed. (Fig. 323.) 

The needle should be passed around the vessel from 
above downward in order to avoid the nerve. 



Ligation of the Facial Artery. 

The facial artery passes over the inferior maxilla just 
in front of the anterior edge of the masseter muscle and 
is accompanied by the facial vein, which lies nearer to the 
muscle. 

Incision either a horizontal one along the lower border 
of the maxilla or a vertical one an inch in length. (Fig. 
322, E.) The skin, subcutaneous tissue, and fascia being 
divided, the artery is exposed and the needle should be 
passed around the vessel away from the vein. 

Ligation of the Occipital Artery. 

Incision two inches in length, starting from a point half 
an inch below and in front of the apex of the mastoid 
process carried obliquely backward parallel to the border 
of this process. (Fig. 322, (7.) Divide the skin and 
fascia and expose the insertion of the sterno-cleido-mastoid 
muscle, which is also divided, and the aponeurosis of the 
splenius is exposed ; this is also opened and the digastric 
groove is felt for, and when the belly of the digastric 
muscle is exposed the artery is brought into view by 
separating the cellular tissue in the anterior angle of the 
wound with a director. (Fig. 324.) 



436 



OPERATIONS. 



Ligation of the. Temporal Artery. 

Incision a transverse one, one inch in length, starting 
from the tragus of the ear forward over the zygomatic 
arch (Fig. 321, D), or a vertical one of the same length a 
little in front of the tragus of the ear. 

Divide the skin and expose the subcutaneous cellular 
tissue, which in this region is very dense and fibrous. This 
tissue should be broken up with a director and the artery 
should be found in it about a quarter of an inch in front 
of the ear. (Fig. 325.) The temporal vein accompanies 



Fig. 324. 



Fig. 325. 




Ligation of the occipital artery. 
(Skey.) 




Ligation of the temporal artery. 
(Skey.) 



the artery and lies nearer to the ear, and in some cases the 
auriculo-temporal nerve is in close relation to the artery. 
The needle should be passed from behind forward. 

Ligation of the Axillary Artery. 



The axillary artery extends from the middle of the 
clavicle to the insertion of the teres major into the 
humerus; the axillary vein lies upon the inner side and in 
front of the artery. The axillary artery is tied either in 



LIGATION OF THE AXILLARY ARTERY 437 

its upper portion, just below the clavicle, or at its lower 
portion in the axilla. 

Ligation of the Axillary Artery Below the Clavicle. 

Incision four inches in length from the summit of the 
coracoid process inward a short distance below the clavicle 
(Fig. 318, E) y or an incision three inches in length, com- 
mencing at a point one-half an inch from the sterno- 
clavicular articulation and carried obliquely downward 
toward the axilla. 

The skin and subcutaneous tissue having been divided 
the deep fascia is exposed and opened, or the axillary 
artery may be reached by following the intermuscular 
space between the sternal and clavicular fibres of the pec- 
toralis major which leads upward toward the clavicle and 
to the pectoralis minor ; or the fibres of the pectoralis 
major being exposed are cut through and the costo-coracoid 
membrane is next torn through with a director, care being 
taken to avoid injury of the cephalic vein at the outer 
portion of the wound ; the pectoralis minor is now seen, 
and after separating the cellular tissue with a director the 
axillary vein is seen crossing from the upper edge of the 
muscle to the clavicle ; the vein almost completely covers 
the artery, which is exposed by drawing the vein inward. 
The needle is passed around the artery from within 
outward. 

Ligation of the Axillary Artery in the Axilla. 

Incision two and a half inches long, started at the upper 
part of the axilla and carried down the arm at the edge of 
the coraco-brachialis muscle. (Fig. 326, A.) The skin 
only is divided in the first incision. The deep fascia is then 
picked up and divided upon a director. As soon as the 
fibres of the inner border of the coraco-brachialis muscle 
are exposed and held aside by a retractor, the operator will 
see the median nerve, the musculo-cutaneous nerve, and 
the axillary artery. To the inner side of the artery are 



438 



OPERATIONS. 



the axillary vein, ulnar and internal cutaneous nerves. 
The needle should be passed around the artery from the 
vein toward the coraco-brachialis muscle. 



Fig. 326. 



%0**- 







* % 



A. Incision for axillary artery in axilla. B. Incision for brachial artery. 
(Stimson.) 

Fig. 327. 




Relations of right axillary artery in axilla. (Esmarch.) 

Ligation of the Brachial Artery. 

Incision at the middle of the arm three inches long on a 
line corresponding to the inner edge of the biceps muscle. 



LIGATION OF THE BRACHIAL ARTERY. 



439 



(Fig. 326, B.) The skin and cellular tissue having been 
divided, care being taken not to injure the basilic vein, 
which should be drawn posteriorly, the deep fascia is next 
cut through and the fibres of the biceps muscle are ex- 
posed (Fig. 328) ; this muscle should be drawn forward, 
and the sheath of the vessels enclosing the artery, veins, 
and median nerve exposed ; the sheath having been opened, 
the median nerve is pressed aside and the artery is sepa- 

Fig. 328. 




Relations ot right brachial artery at middle of arm. (Esmarch.) 

rated from its veins, and the needle is passed from the side 
of the nerve around the vessel. 

In ligating the brachial artery the occasional high 
division of the vessel must be borne in mind. 



Ligation of the Brachial Artery at Bend of the Elbow. 

Incision two inches in length, along the inner border of 
the tendon of the biceps muscle. Divide the skin, super- 
ficial fascia, and the bicipital aponeurosis, under which 
the artery will be exposed, resting upon the brachialis 
anticus muscle. (Fig. 329.) The median nerve is to the 



440 OPERATIONS. 

inner side and some distance from the artery. The needle 
should be passed around the vessel, after isolating the 
veins, from within outward. 

Fig. 329 

Tendinous aponeurosis 
divided. 




Ligation of the brachial artery at the bend of the elbow. (Bryant.) 

Ligation of the Radial Artery. 

The radial artery extends in a straight line from a point 
half an inch below the centre of the fold of the elbow to 
the inner side of the styloid process of the radius. 

The radial artery may be tied at its upper, middle, or 
lower third, or at the root of the thumb. 

Ligation of the Radial Artery in the Upper Third of the 
Forearm. 

Incision for the radial artery at its upper third is two 
and a half inches in length on a line drawn from the 
middle of the bend of the elbow to the ulnar side of the 
styloid process of the radius ; the incision should begin 
one and a half inches below the bend of the elbow. (Fig. 
330, A.) Divide the skin and superficial fascia, avoiding 
the superficial veins. When the deep fascia is exposed, 
find the edge of the supinator longus muscle and divide 
the aponeurosis along its ulnar side, and expose the fibres 
of the pronator radii teres muscle. The vessel lies in the 
interspace between these muscles surrounded by adipose 



LIGATION OF THE RADIAL ARTERY, 



441 



tissue, and upon being exposed the veins should be iso- 
lated and the needle passed from without inward. The 



Fig. 330. 



Fig. 331. 





Relations of right radial artery in 
the upper third of the forearm. 
(Esmarch.) 

Fig. 332. 




Line of incision for— A. Radial artery 
in upper third. B. Radial artery in 
lower third. C. Ulnar artery in upper 
third. D. Ulnar artery in lower third. Relations of right radial artery above 
(Stimsox.) the wrist. (Esmarch.) 

radial nerve lies so far external to the artery that it is not 
often exposed in the operation. (Fig. 331.) 

Ligation of the Radial Artery in the Middle Third of the 

Forearm. 

Incision two inches in length, following the same line 
as that for the upper third of the artery. After dividing 



442 OPERATIONS. 

the skin, superficial and deep fascia, the artery is found 
in the interspace between the flexor carpi radialis on the 
inner side and the supinator longus on the outer side ; the 
radial nerve at this part of the arm is in close relation 
with the vessel to the radial side, and the needle should 
be passed around the artery from without inward. 

Ligation of the Radial Artery in the Lower Third of the 

Forearm. 

Incision two inches in length following the same line 
(Fig. 330, JS), ending one inch above the wrist. The skin, 
superficial fascia, and deep fascia being divided, the artery 
will be found between the tendon of the flexor carpi 
radialis on the inner side and the tendon of the supinator 
longus on the outer side. (Fig. 332.) The veins being 
separated the needle may be passed in either direction. 

Ligation of the Radial Artery at the Root of the Thumb. 

The radial artery may also be tied at the root of the 
thumb. 

Incision one inch in length between the tendons of the 
extensor ossis metacarpi pollicis and extensor primi inter- 
nodii pollicis on the outer side, and the tendon of the ex- 
tensor secundi internodii pollicis on the inner side. The 
skin and superficial fascia being divided, and the radial 
vein being displaced, the deep fascia is opened and the 
artery is exposed at the bottom of the wound ; the needle 
may be passed in either direction. 

Ligation of the Ulnar Artery. 

The ulnar artery is tied at the junction of the upper 
and middle third of the forearm and at the lower third. 

Ligation of the Ulnar Artery at the Junction of the Upper 
and Middle Thirds of the Forearm. 

Incision three inches in length, starting four inches below 
the internal condyle of the humerus, on a line passing from 



LIGATION OF THE ULNAR ARTERY. 



443 



the internal condyle of the humerus to the outer border of 
the pisiform bone. (Fig. 330, C and D.) Divide the skin 
and superficial fascia, and when the deep fascia has been 
exposed the interspace between the flexor carpi ulnaris and 
the flexor sublimis digitorum appears, enter this interspace 



Fig. 333. 




Relations of the right ulnar artery at upper third of the forearm. (Esmakch ) 



and raise the flexor sublimis digitorum and work trans- 
versely across the arm. The artery will be found rest- 
ing upon the deep flexor, with the ulnar nerve to the ulnar 
side. The needle should be passed from the nerve around 
the artery. (Fig. 333.) 

Ligation of the Ulnar Artery in the Lower Third of the 
Forearm. 

Lneision two inches in length a little to the radial side 
of the tendon of the flexor carpi ulnaris, which is at- 
tached to the pisiform bone, ending an inch above the 
wrist. (Fig. 330, D.) Divide the skin and superficial 
fascia and open the deep fascia, and the artery will be ex- 
posed, with its accompanying veins, between the tendons 
of the flexori carpi ulnaris and flexor sublimis digitorum, 
the ulnar nerve being to the ulnar side of the vessel. 



444 OPERATIONS. 

The needle should be passed from within outward to 
avoid the nerve. (Fig. 334.) 




Relations of right ulnar artery above the wrist. (Esmarch.) 

Ligation of the Interosseous Artery. 

Incision similar to that employed in the ligation of the 
ulnar artery in its upper third. 

Ligation of the Abdominal Aorta. 

Incision in the linea alba from a point three inches 
above the umbilicus to a point three inches below it. The 
superficial structures being divided, the peritoneum is 
opened upon a director, and the intestines are pressed aside 
and the aorta is exposed covered by peritoneum, with the 
filaments of the sympathetic nerve resting upon it, and 
the vena cava to the right side. Tear through the peri- 
toneum and pass the needle from left to right around the 
vessel. After tying the ligature the ends should be cut 
short, and the external wound should be closed as in the 
ordinary coeliotomy wound. 

The vessel may also be exposed by an incision along the 
anterior border of the quadratus lumborum muscle, from 
the last rib to the crest of the ilium. The skin, lumbar 
muscles, and fascia transversalis being divided, the wound 
is held open with blunt hooks, so that the retro- peritoneal 
space is exposed and the aorta brought into view. The 



LIGATION OF THE COMMON ILIAC ARTERY. 445 

vessel being separated from the vena cava and nerves, the 
needle is passed around it and the ligature applied. 

Ligation of the Common Iliac Artery. 

The aorta divides into the two common iliac arteries on 
the left side of the fourth lumbar vertebra, and these 
arteries are usually about two inches in length, and 
bifurcate opposite the sacro-iliac synchondrosis to form 
the internal and external iliac arteries ; the length of the 
common iliac artery, however, may vary considerably, 
being three or four inches in length in some cases. 

Fig. 335. 




Line of incision for— A, common iliac artery. B, external iliac artery. 
C, femoral artery in Scarpa's triangle. (Stimson.) 

Incision for ligation of the common iliac artery is four 
to six inches in length, beginning one-half inch above the 
middle of Poupart's ligament, and is carried outward, 
curving upward after passing the anterior superior spine 
of the ilium. (Fig. 335, A.) 

Divide the skin, superficial fascia and aponeurosis of 
the external oblique muscle, and then divide the fibres of 
the internal oblique and transversalis muscles upon a 
director and expose the transversalis fascia. This is 
opened at the lower part of the wound, and the finger is 

20 



446 



OPERATIONS. 



introduced and the peritoneum is pressed back ; the open- 
ing in the transversalis fascia is next enlarged, and the 
peritoneum is carefully drawn inward and upward with 
the fingers toward the inner edge of the wound. The 
operator next feels for the external iliac artery, and passes 
the finger along this until the common iliac artery is 
beached. The loose cellular tissue in which it is imbedded 
is next separated, and the needle is passed from within 
outward, to avoid the common iliac vein (Fig. 336), which 

Fig. 336. 




Ligation of the common iliac artery. (Liston.) 

on the left side lies on the inner side of the artery, and 
on the right side lies behind the artery. The ureter 
generally remains attached to the peritoneum; if not, it is 
seen crossing the bifurcation of the common iliac with the 
genito-crural nerve, and care should be taken to avoid 
injury of these structures if present. 

The common iliac artery may also be exposed and tied 
by an incision made over the artery through the peritoneal 
cavity ; the vessel being tied, the ends of the ligature are 



LIGATION OF THE EXTERNAL ILIAC ARTERY. 447 

cut short, and the external wound is closed in the same 
manner as that resulting from the exposure of the ab- 
dominal aorta by incision through the peritoneum. 

Ligation of the Internal Iliac Artery. 

Incision in the same line as for the common iliac artery, 
but it need not be quite so long. (Fig. 335, A.) The peri- 
toneum being exposed, it is pushed upward and inward, 
and the internal iliac artery is exposed. The vessel is care- 
fully isolated from the vein, which lies behind and on the 
inner side, and the needle is passed from within outward. 

Ligation of the External Iliac Artery. 

Incision three or four inches in length, half an inch 
above the middle of Poupart's ligament, made at first par- 




Relations of the right external iliac artery. (Esmarch.) 

allel to it and then curved upward. (Fig. 335, B.) The 
tissues of the abdominal wall being divided and the peri- 



448 



OPERATIONS. 



toneum exposed, it is pushed upward and inward in the 
same manner as for exposure of the common iliac artery. 
The artery lies at the inner border of the psoas muscle, 
the vein on its inner side, and the anterior crural nerve 
covered by the iliac fascia on the outer side; the genito- 
craral nerve passes obliquely across the artery. (Fig. 337.) 
The needle should be passed from within outward. 

Ligation of the Gluteal, Artery. 

Incision three or four inches in length, from the posterior 
superior spinous process of the ilium to a point midway 
between the tuber ischii and the great trochanter. (Fig. 
338, A.) After division of the skin and fascia, the fibres 

Fig. 338. 




Line for — A, gluteal artery. B, sciatic and internal pudic artery. (Stimson.) 



of the gluteus maximus muscle are separated and held 
apart, and the deep fascia is divided, and the artery should 
then be sought for above the pyriformis muscle at the 
upper border of the great sacro-sciatic notch. It is accom- 



LIGATION OF THE FEMORAL ARTERY. 



449 



panied by large veins, injury to which should be avoided 
in exposing the artery and passing the needle. 

Ligation of the Sciatic and Internal Pudic 
Arteries. 

Incision three or four inches in length, a little lower 
than that employed for exposure of the gluteal artery. 
(Fig. 338, B.) Divide the skin, superficial fascia and 
fibres of the gluteus maximus muscle and deep fascia, and 
search for the vessels as they leave the great sciatic notch 
at the lower edge of the pyriformis muscle. The internal 
pudic artery enters the pelvis through the lesser sciatic 
notch, lying on the inner side of the sciatic artery during 
its passage over the spine of the ischium. The vessels are 
isolated and the needle is passed so as to avoid injury of 
the veins. 

Ligation of the Femoral Artery. 

The femoral artery may be ligated just below Poupart's 
ligament, at the apex of Scarpa's triangle, at the middle of 
the thigh, or in Hunter's canal. 

Fig. 339. 




Relations of the right femoral artery below Poupart's ligament. (Esmarch.) 



450 OPERATIONS. 

Ligation of the Femoral Artery below Poupart's Ligament: 

Incision beginning midway between the anterior superior 
spinous process of the ilium and the symphysis pubis, 
one-fourth of an inch above Poupart's ligament, and ex- 
tending two inches downward. Divide the skin and super- 
ficial fascia and the deep fascia so as to expose the sheath 
of the vessels; open this one-half an inch below Poupart's 
ligament and isolate the femoral artery from the femoral 
vein which lies to the inner side; the anterior crural nerve 
lies to the outer side. Pass the needle from within out- 
ward. (Fig. 339.) 

Ligation of the Femoral Artery at the Apex of Scarpa's 
Triangle. 

Incision three inches long, the centre of which should be 
a little above the point where the sartorius muscle crosses 

Fig. 340. 




m 



Lines of incision for the femoral artery. (Stimson.) 

a line drawn from the middle of Poupart's ligament to the 
inner condyle of the femur. (Fig. 340.) Divide the skin, 
superficial fascia and deep fascia, avoiding the internal 
saphenous vein, and expose the edge of the sartorius 
muscle, which may be recognized by the direction of its 



LIGATION OF THE FEMORAL ARTERY. 



451 



fibres. This muscle is drawn outward and the sheath of 
the vessels is exposed and opened ; the vein lies on the 
inner side and somewhat behind the artery and the long 
saphenous nerve is on the outer side. (Fig. 341.) Pass 
the needle from within outw r ard. 

Ligation of the Femoral Artery in the Middle of the 
Thigh. 

Incision in the line above mentioned, its centre being a 
little above the middle of the thigh. Divide the skin, 
superficial and deep fascia and expose the sartorius muscle, 
which is drawn outward after the leg has been flexed ; 



Fig 341. 



Fig. 342. 




Relations of right femoral 
artery at the apex of Scarpa's 
triangle. (Esmarch.) 




Relations of the right femoral 
artery in the middle of the thigh. 
(Esmarch.) 



the sheath of the vessel is exposed and opened ; the long 
saphenous nerve lies upon the artery and the femoral vein 
lies behind the artery ; the saphenous vein lies more super- 
ficially and internal to the vessel. Pass the needle from 
within outward. (Fig. 342.) 



452 



OPERATIONS. 



Ligation of the Femoral Artery in Hunter's Canal. 

Incision three inches in length along the tendon of the 
adductor magnus, the centre of which is at the junction of 
the lower and middle thirds of the thigh. (Fig. 340.) 
Divide the skin, superficial fascia and deep fascia, care 
being taken not to injure the internal saphenous vein, 
which should be displaced, and expose thesartorius muscle, 
which should be displaced downward, and expose the 
aponeurosis which forms the anterior wall of the vascular 
canal ; this should be opened upon a director, and the 
artery is uncovered and should be separated from the vein, 
which lies upon the outer side. The needle is passed from 
without inward. 



Ligation of the Popliteal Artery. 

Fig. 343. 




aO Relations of the right popliteal artery. (Esmarch. 



LIGATION OF THE ANTERIOR TIBIAL ARTERY. 453 

Incision three or four inches in length, along the exter- 
nal border of the semi-membranosus muscle. Divide the 
skin and superficial fascia, taking care not to injure the 
saphenous vein, and open the deep fascia. The edges of 
the wound being held apart the adipose tissue is broken 

Fig. 344. 



Ligation of popliteal artery. (Smith.) 

up with a director, and the internal popliteal nerve will 
be first exposed, and next the vein — both external to the 
artery. (Fig. 343.) The artery is isolated and the needle 
passed from without inward. (344.) 

Ligation of the Anterior Tibial Artery. 

The anterior tibial artery may be tied in the upper, 
middle, and lower thirds of the leg ; the general direction 
of the artery corresponds with a line drawn from the 
middle of the space between the head of the fibula and the 
tubercle of the tibia to the middle of the anterior inter- 
malleolar space. 

Ligation of the Anterior Tibial Artery in the Upper Third 
of the Leg. 

Incision two and a half to three inches in length, one 
and one-fourth inches external to the spine of the tibia. 
Divide the skin and superficial fascia, and when the deep 

20* 



454 



OPERATIONS. 



Fig. 345. 




fascia is exposed open it on a line corresponding to the 
inter-muscular space between the tibialis anticus and the 
extensor longus digitorum mus- 
cles. Separate the muscles and 
work down in this interspace 
until the artery is found with a 
vein on either side of it, and the 
anterior tibial nerve externally. 
(Fig. 345.) The needle should 
be passed from without inward, 
after isolating the veins. 

Ligation of the Anterior Tibial 
Artery at its Middle Third. 

Incision three inches in length 
in the same line as that for the 
upper portion of the vessel. After 
dividing the skin, superficial and 
deep fascia, the interspace between 
the tibialis anticus and the exten- 
sor longus digitorum muscles is 
opened and a third muscle comes 
into view, the extensor proprius 
pollicis. The artery lies between 
the extensor proprius pollicis and 
the tibialis anticus muscles; and the anterior tibial nerve 
is to the outer side. The veins should be isolated and the 
needle should be passed from without inward. 



Ligation of the anterior tib- 
ial artery at its upper third. 
(Stimson.) 



Ligation of the Anterior Tibial Artery in its Lower Third. 

Incision two inches in length, beginning three inches 
above the ankle-joint on the line of the artery. Divide 
the skin, superficial and deep fascia, and seek for the 
tendon of the extensor proprius pollicis muscle, the second 
tendon from the tibia. The artery is found in the inter- 
space between this tendon and the tendon of the extensor 
longus digitorum muscle, the nerve being to the outer side. 



LIGATION OF THE DORSALIS PEDIS ARTERY. 455 

The veins are isolated from the artery, and the needle is 
passed from without inward. 



Ligation of the Dorsalis Pedis Artery. 

Incision one inch in length on a line drawn from the 
middle of the anterior inter-malleolar space to a point 
midway between the extremities of the first two metatarsal 
bones or along the outer border of the tendon of the ex- 
tensor proprius pollicis. Divide the skin, superficial and 



Fig. 346. 



Extensor 

brevis digitorum 

muscle. 




Ligation of the dorsalis pedis artery. (Bryant.) 



deep fascia, and the artery will be found lying next to 
the inner tendon of the short extensor muscle of the toes. 
(Fig. 346.) The nerve is to the outer side. After separating 
the veins the needle is passed from without inward. 



456 



OPERATIONS. 



Ligation of the Posterior Tibial Artery. 



The course of the posterior tibial artery is indicated 

by a line drawn from the middle of the popliteal space to 

a point midway between the tendo 

fig. 347. Achillis and the internal malleolus 

of the tibia. 

The posterior tibial artery may 
be ligated in its upper, middle, and 
lower thirds. 

Ligation of the Posterior Tibial 
Artery at its Upper Third. 

Incision three inches and a half 
in length, one-half inch from the 
inner edge of the tibia, beginning 
two inches from the upper edge of 
the bone. (Fig. 347.) Divide 
the skin and superficial fascia, 
avoiding large superficial veins ; 
next open the deep fascia and de- 
tach the origin of the soleus muscle 
from the tibia, and on raising it its 
under surface will present a white 
shining sheath of tendinous mate- 
rial, beneath which will be seen a 
layer of fascia covering the tibialis 
posticus muscle. If search is made 
toward the middle of the leg, the 
artery will be found covered by the inter muscular fascia, 
the nerve being to the outer side. The needle is passed 
from without inward after the veins have been separated 
from the artery. (Fig. 348.) 

Ligation of the Posterior Tibial Artery at its Middle Third. 

Incision two and a half inches in length, parallel with 
the inner edge of the tibia and half an inch from its 




Lines of incision for the 
posterior tibial artery. 
(Stimson.) 



LIGATION OF POSTERIOR TIBIAL ARTERY. 457 

border. Divide the skin, superficial and deep fascia, and 
the inner edge of the soleus will be exposed ; press this 
outward and the artery with its veins will be exposed, also 

Fig. 348. 




Relations of the right posterior tibial artery in its upper third. (Esmarch.) 



the posterior tibial nerve to the outer side. Pass the needle 
from without inward after separating the veins. 

Ligation of the Posterior Tibial Artery Behind the Inner 
Malleolus. 

Incision a curved one two inches in length, midway 
between the tendo Achillis and the internal malleolus. 
(Fig. 349.) Divide the skin and superficial fascia; then 
lift the deep fascia upon a director and opn it freely, 
when the artery will be exposed with the tendons of 
the tibialis posticus and flexor longus digitorum mus- 
cles on the inner side, and the posterior tibial nerve and 
the tendon of the flexor longus pollicis muscle on the 



458 



OPERATIONS. 

Fig. 349. 




Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) 

outer side. (Fig. 349.) After separating the veins 
from the artery the needle should be passed from without 
inward. 



PART VI 



AMPUTATIONS. 



The term amputation is now generally applied to the 
removal of a limb, and this may be removed through the 
bones, when the operation is spoken of as an amputation 
in the continuity of the limb ; or it may be removed 
through its joints, and is then known as an amputation in 
the contiguity or a disarticulation. 

Methods of Amputating. 

Fig. 350. 




Amputation by circular method. (Druitt.) 

Amputations may be performed by the circular flap, 
oval, and elliptical methods; the modified circular opera- 



460 



AMPUTATIONS. 



Fig. 351. 



tion, and Teale's method by rectangular flaps, are also em- 
ployed. 

Circular Method. 

In performing an amputation by this method the inci- 
sion of the skin is made at a distance below the point 
where the bone is to be divided. An assistant grasps the 
limb and draws the skin evenly and firmly toward the 
root of the part and the surgeon passes the heel of the 

knife well into the tissues and 
makes a circular sweep around 
the limb and completes the di- 
vision of the skin and cellular 
tissue with one motion of the 
knife. (Fig. 350.) 

In some cases a cutaneous 
sleeve consisting of the skin 
and cellular tissue is dissected 
up and turned back, and some- 
times it may be necessary to 
make a slit on one side of the 
flap to allow it to be turned up. 
The second incision in an am- 
putation by the circular method 
consists, after retraction of the 
skin, in making a circular cut through all of the tissues 
down to the bone. (Fig. 351.) 

The third step in an amputation by the circular method 
consists, after retracting the skin and muscles and holding 
them back by a retractor, in the division of the bone with 
a saw. 

Flap Method. 

This method of amputating is susceptible of many 
variations. There may be one or two flaps of equal or 
unequal length ; the flaps may be cut antero-posteriorly, 
laterally, or obliquely. (Fig. 352.) They may be made 
by transfixing the limb and cutting outward, or they may 
be cut from without inward, or they may be made to in- 




Division of muscles in circular 
amputation. (Smith.) 



METHODS OF AMPUTATING. 



46 L 



elude the whole thickness of the tissues down to the bone, 
or merely the skin and superficial fascia, the deeper struc- 
tures being divided by a circular incision. The flaps may 



Fig. 352. 




Double-flap amputation ; antero-posterior and lateral flaps. (S. Smith.) 

have a curved outline or may be rectangular in shape. In 
amputating by the antero-posterior flap operation the sur- 

FlG. 353. 




Amputation by antero-posterior flaps. (Bryant.) 



geon grasps the limb and enters the point of a long knife 
into the tissues at the side nearest himself, and pushing it 



462 AMPUTATIONS. 

across and around the bone or bones brings its point out 
through the skin at a point diametrically opposite its point 
of entrance. He then shapes the flap by cutting down- 
ward with a rapid sawing motion and then cuts obliquely 
forward until all the tissues are divided. The flap being 
turned up, he re-enters his knife at the same point and 
passes it on the other side of the bone or bones and cuts 
the second flap in the same manner. (Fig. 353.) A re- 
tractor is next applied and the bone is divided with a saw. 

The Oval Method. 

The oval amputation is really a circular one in which 
the cuff of skin has been slit at one side and the angles 
rounded off. This is the form of amputation frequently 
performed at the metacarpo-phalangeal and metatarso- 
phalangeal joints, and is one of the methods of amputation 
at the shoulder-joint. 

Elliptical Method. 

This is a form of the oval method of amputation which 
is employed in amputations at the knee- and elbow-joints, 

Fig. 354. 




Modified circular amputation. (Skey.) 



METHODS OF AMPUTATING. 



463 



the incision forming an ellipse coming below the joint on 
the front or outside of the limb, the resulting flap being 
folded upon itself. 



Modified Circular Method. 

In this method of amputation two oval skin flaps, 
antero-posterior or lateral, are turned up, and the muscles 
are next divided by a circular sweep of the knife down to 
the bone. (Fig. 354.) 

Teale's Method by Rectangular Flaps. 

In this method of amputation, two flaps are made of 
unequal length ; the incisions are so planned that the 
shorter flap contains the main vessel or vessels. The 

Fig. 355. 




Teale's method of amputation. (Bryant.) 

flaps are cut of equal width and the length of the long 
flap should be one-half of the circumference of the limb at 
the point where the bone is to be divided ; the length of 
the short flap should be one eighth of the circumference of 
the limb. The flaps are cut from without inward, and 
embrace all of the tissues of the limb down to the bone. 
After the flaps have been dissected up, the bone is divided 



464 AMPUTATIONS. 

with a saw, and the long flap is folded over and sutured 
to the short flap (Fig. 355). The disadvantage of this 
method of amputation is that in muscular limbs it requires 
the bone to be divided at a higher point than would 
otherwise be necessary. 

Periosteal Flaps. 

In any of the methods of amputation previously de- 
scribed the periosteum may be dissected up in two flaps 
attached to the muscles, or pushed up as a sleeve by means 
of a director or periosteotome before the bone is sawed. 
This procedure is most easily accomplished in young sub- 
jects. When these flaps are made and they are brought 
together, the periosteum covers the cut surface of the bone, 
to which it soon forms adhesions. 



Instruments Required for Amputations. 

The instruments required for amputations are knives 
of various shapes and sizes, saws, dissecting forceps, bone 
forceps, artery forceps, tenacula, haemostatic forceps, scis- 
sors, periosteotome, tourniquets, Esmarch's bandage and 
strap, retractors, ligatures, sutures, and suture needles. 

Amputating Knives. 

The knives required for amputations vary according to 
the method of amputation and the part to be amputated. 

Fig. 356. 



Scalpel. 

In certain amputations a scalpel (Fig. 356) or straight 
bistoury may be used (Fig. 357), while in other cases the 
employment of amputating knives of various sizes will be 
found more satisfactory. For amputations of the thigh a 



INSTRUMENTS REQUIRED FOR AMPUTATION. 465 

knife with a blade of eight or nine inches is generally 
employed, and for smaller limbs a knife with a blade of 
six or seven inches in length ; double-edged catlins are 

Fig. 357. 



Straight bistoury. 

employed in amputations of the leg and forearm to divide 
the interosseous tissues before applying the saw. The 
amputating knives now employed are constructed with 

Fig. 358. 



Amputating knife and catlin. 

solid metal handles so that they can be rendered thoroughly 
aseptic by immersion in boiling water before being used. 
(Fig. 358.) 

Amputating Saws. 

Several kinds of amputating saws are in general use ; 
one with a blade ten inches long by two and a half inches 

Fig. 359. 




Amputating;saw. 



wide, with a heavy back to give it additional firmness, is 
a very good variety of saw (Fig. 359). For amputations 



466 



AMPUTATIONS. 



about the foot or hand a narrow saw with a movable back 
will be found very convenient. (Fig. 360.) A bow saw 



Fig. 360. 




Small amputating saw. 



with a metallic handle and a reversible blade is a very 
useful variety of saw, as it can be used either in amputa- 



FlG. 361. 




§R1I 



Amputating saw with reversible blade. 



tions or in excisions, and, being constructed entirely of 
metal, it can be easily rendered aseptic. (Fig. 361.) 

Bone-forceps, or Cutting Pliers. 

These instruments are used in smoothing off any rough 
edges of bone left after the use of the saw, or for the 

Fig. 362. 




Bone-forceps, or cutting pliers. 



division of the small bones in amputations of the fingers 
and toes. The forceps should be from ten to twelve 



INSTRUMENTS REQUIRED FOR AMPUTATION 467 

inches in length, with blades from one to one and a half 
inches in length. (Fig. 362.) 

Periosteotome. 

The periosteotome, or raspatory, is employed for dis- 
secting up a flap of periosteum, which, after sawing the 

Fig. 363. 



Periosteotome. 

bone, is drawn down over the sawed end of the bone. 

(Fig. 363.) 

Artery Forceps and Tenaeula. 

These instruments are used for taking up the vessels, 
and one of the best forms of artery forceps is that known as 
the double-spring artery forceps. (Figs 208 and 209.) 
Tenaeula are also employed for the same purpose. Haemo- 
static forceps will also be found most useful in cases of 
amputation, for the rapid control of hemorrhage from 
small vessels after the tourniquet has been removed, the 
vessels beiug secured by ligatures before the haemostatic 
forceps are removed. 

Retractors. 

These consist of pieces of muslin six or eight inches in 
width, one end of which is split into two or three tails ; 
the former variety of retractor is employed where one 
bone is divided, as in amputations of the arm and thigh, 
and the latter in cases where two bones are divided, as in 
amputations of the forearm and leg. (Fig. 364.) 



468 



AMPUTATIONS. 
Fig. 364. 




Retractor applied. (Esmaech.) 

Ligatures. 

The best material to employ for the ligature of vessels 
is juniper or chromicized catgut or sterilized silk, the 
preparation of which has been described. 



Sutures. 



Fig. 365. 



Fig. 366. 




Deep or buried sutures of muscles. 
(Esmarch.) 



Sutures of the skin. 
(Esmarch.) 



DETAILS OF AN AMPUTATION. 469 

The materials employed for sutures in cases of amputa- 
tion may be silkworm-gut, catgut, silk, or silver wire ; 
deep or buried sutures of catgut in bringing together the 
edges of the periosteal flaps, muscles, and fascia, are often 
employed with advantage in amputations (Fig. 365), the 
skin flaps being brought together with interrupted or 
continuous sutures of silk, catgut, silkworm-gut, or silver 
wire. (Fig. 366.) 

Tourniquets. 

For the control of hemorrhage during the amputation 
the Esniarch's apparatus (Fig. 206) or Petit's tourniquet 
(Fig. 199) is employed ; or the employment of both at the 
same time will often be found most satisfactory. The 
Esmarch bandage and tube being applied, after the removal 
of the bandage the tourniquet of Petit is loosely applied 
at a higher point, and after the main vessels have been 
secured the elastic strap is removed, and the tourniquet is 
screwed down and controls the bleeding until the smaller 
vessels have been secured by ligatures. 

Details of an Amputation. 

The following are the steps of an amputation of the 
lower part of the thigh : 

The skin is first thoroughly cleansed by rubbing it 
with turpentine, soap and water. It is then washed with 
an antiseptic solution either of carbolic acid 1 : 40 or 
bichloride of mercury 1 : 2000. Provision is next made 
to prevent the loss of blood during the operation by the 
application of Esmarch's bandage and tube ; the bandage 
being removed a tourniquet is placed over the femoral 
artery in Scarpa's triangle and loosely secured. The limb 
is again washed with bichloride solution. The instruments 
having been previously thoroughly sterilized, a rubber 
cloth covered with towels wrung out in a bichloride solu- 
tion is placed under the limb. The variety of amputation 
having been decided upon, the flaps are cut and the muscles 

21 



470 



AMPUTATIONS. 



are divided down to the bone ; the periosteum being dis- 
sected up, a two-tailed retractor is applied, and the tissues 
are held back by an assistant while the surgeon divides 
the bone with the saw. When the bone has been divided 
the retractor is removed, and the surface of the wound is 
irrigated with a 1 : 2000 bichloride solution. The femoral 
artery and vein are next found and secured with ligatures, 
and any branches which can be found are also secured. 
The elastic strap is removed after screwing down the 
tourniquet, and by letting up the pressure on this smaller 

Fig. 367. 




Stump showing application of sutures and drainage-tubes. (Smith.) 

vessels which bleed are picked up with artery forceps or 
haemostatic forceps and secured. After all bleeding has 
been controlled the tourniquet is removed, and the wound 
is again thoroughly irrigated with a 1 : 2000 bichloride 
solution. If there is much oozing from the smaller vessels, 
this solution should be as hot as the hands of the operator 
can comfortably stand, which will act promptly in con- 
trolling this variety of bleeding. The periosteal flaps, if 
they have been made, are brought together by two or three 
catgut sutures, and a drainage-tube is next introduced or 
two short tubes are introduced at either extremity of the 



RE-DRESSIXG OF AMPUTATIONS. 47 1 

wound and secured by sutures or safety-pins ; the muscles 
should next be brought together by a few deep or buried 
sutures of catgut, and the skin flaps should then be 
brought into apposition by a number of interrupted 
sutures. The inner surface of the stump is next irrigated 
by a stream of bichloride solution introduced through the 
drainage-tube, and the surface of the stump is washed 
with the same solution ; a piece of protective is next 
placed over the line of the wound and over this is placed 
a moist carbolized, bichloride, or iodoform gauze dressing, 
and over this a number of layers of dry gauze ; this is 
next covered by rubber tissue and a number of layers of 
bichloride cotton, or, if the dry method of dressing is pre- 
ferred, the rubber tissue is omitted and a number of layers 
of bichloride cotton are laid over the gauze dressing, and 
the whole dressing is held in place by a recurrent bandage 
of the stump. 

If the aseptic method is employed, no antiseptic solu- 
tions are brought in contact with the wound, sterilized 
water only being used if it is necessary to flush the wound, 
and after bringing the flaps together a sterilized gauze 
dressing is applied. 

Re-dressing of Amputations. 

The first dressing of an amputation, if strict antiseptic 
precautions have been observed at the time of operation, 
need not, as a rule, be made for a week or ten days, except 
in cases where the oozing is so profuse as to soak the dress- 
ings, or where consecutive hemorrhage has occurred, or 
the patient's condition shows that the wound is not running 
an aseptic course. The re-dressing of a stump can be ac- 
complished without pain to the patient if the surgeon and 
his assistants are careful in their manipulations. 

The dressings to be applied, the solutions for irrigation, 
and the instruments required, should be prepared and at 
hand before the stump is exposed. The surgeon and his 
assistants should wash their hands carefully, and then dip 
them in a 1 : 2000 bichloride solution. The bandage re- 



472 AMPUTATIONS. 

taining the dressings to the stump should be divided with 
bandage scissors without lifting the stump from the pillow 
upon which it rests. After the bandage has been divided 
and turned aside, the gauze dressing is next unfolded and 
turned down ; an assistant now slips his hands under the 
stump and gently raises it from the dressings, and at the 
same time a rubber cloth covered with towels which have 
been wrung out in a 1 : 2000 bichloride solution is slipped 
under the stump and the soiled dressings are removed. 
The protective covering the incision is next removed and 
the surface of the stump is irrigated with a 1 : 2000 bichlo- 
ride solution ; the drainage-tubes are next examined and 
the cavity of the stump irrigated with the bichloride solu- 
tion through the tubes by means of a syringe or an irri- 
gating apparatus, or the irrigation may be omitted. 

If the wound is aseptic and there seems to be no further 
indication for the use of the drainage-tubes, they may be 
removed and the track of the tube should be washed out 
with the antiseptic solution by the syringe or irrigator. 
The sutures are next examined, and if the wound is firmly 
healed alternate sutures may be removed ; if catgut or 
silkworm-gut sutures have been used, they need not be 
disturbed at this dressing, and their removal may be post- 
poned until a subsequent dressing. 

The wound should next be covered with a piece of pro- 
tective, and a gauze dressing should be applied consist- 
ing of a number of layers, and over this several layers 
of bichloride cotton, and the dressings should be held in 
place by a recurrent bandage of the stump, In holding 
the stump the assistant should hold it firmly to prevent 
muscular spasm, and after the dressings have been secured 
it should be placed upon a clean pillow prepared for its 
reception. The same procedures are adopted at subsequent 
dressings, and if the wound has run an aseptic course, two 
or three dressings, at most, will be required. 



AMPU1AT10NS OF THE HAND. 473 

Special Amputations. 
Amputations of the Hand. 

Amputations of the Fingers. 

The fingers may be amputated in the continuity of the 
phalanges or in their contiguity, and, as a rule, as it is 
important to save as much as possible of the finger, the 
former method is generally to be employed instead of dis- 
articulation at a higher point. The incision should be so 
planned that the cicatrix does not occupy the palmar sur- 
face ; the larger flap should, therefore, be taken from the 
palmar aspect of the finger. In amputating the phalanges 
of the fingers in their continuity the circular method (Fig. 

Fig. 368. 




Amputation of a finger by the long palmar flap. (Erich sen.) 

371, B) or a short dorsal flap and a long palmar flap may 
be employed. In disarticulating a phalanx it is best to 
enter the joint with a narrow knife from the dorsal side, 
and after having carried it through the joint, to cut a long 
palmar flap, keeping close to the bone. (Fig. 368.) In 



474 



AMPUTATIONS. 



locating the position of the phalangeal joints, it is well to 
remember that the prominence of the knuckle when the 
finger is flexed is formed entirely of the head of the proxi- 



Fig. 370. 



Fig. 369. 





Phalanges flexed. 



Guides to articulations of the finger. 
(Smith.) 

imal, and not of the base of the distal phalanx (Fig. 369), 
and also that the folds on the palmar surface of the finger 
do not correspond exactly to the joints. (Fig. 370.) 

Amputation of the Finger through the Metacarpo- 
phalangeal Articulation. 

In this variety of amputation an incision is made from 
a point of the dorsal surface of the metacarpal bone a 
quarter of an inch above the articulation, which is carried 
through the interdigital web and back upon the palmar 
surface to a point a quarter of an inch above the flexor 
fold (Fig. 371, C). A similar incision beginning and 
ending at the same points is made upon the opposite side 
of the finger. The flaps are dissected back, and the lateral 
ligaments, tendons, and remainder of the capsule are 



AMPUTATIONS OF THE HAND. 



475 



divided. The finger may also be amputated at the meta- 
carpophalangeal joint by making an incision on one side 
and dissecting the flap back to the joint, then dividing the 
lateral ligament, opening the joint and carrying the knife 
across this, dividing the tendons and lateral ligament on 
the other side and cutting a flap from within outward. 

Fig. 371. 




A. Disarticulation of phalanx ; palmar flap. B. Amputation in continuity 
by a circular flap. C. Metacarpophalangeal disarticulation. D. Amputation 
of metacarpal bone in continuity. E. Disarticulation of little finger. F. Dis- 
articulation of fifth metacarpal bone. G. Amputation at the wrist, circular. 
H. Amputation at the wrist. (Stimson.) 



Removal of the head of the metacarpal bone if desired 
may be accomplished by the use of cutting pliers (Fig. 372) ; 
but, as a rule, this procedure is not to be recommended, 
for, although the deformity is diminished, the strength of 
the hand is also diminished. 



476 AMPTJTA TIONS. 

In amputating the little and index fingers a full lateral 
flap may be cut on the free side and an incision is next 
carried across the palmar surface to the angle of the web 
and thence back to the joint, which is opened and the dis- 
articulation effected. (Fig. 371, E.) 

Fig. 372. 




Removal of the head of a metacarpal bone. (Skey.) 

In amputations of the finger at the phalangeal joints or 
at the metacarpo-phalangeal joints two vessels usually re- 
quire ligaturing, and after these are secured a catgut drain 
or a small drainage-tube is introduced and the flaps are 
brought together by a few interrupted sutures. 

Amputations of the Metacarpal Bones. 

In amputating the metacarpal bones it is advisable to 
leave the carpal ends of the bones to avoid opening the 
wrist-joint, except in the case of the first and fifth meta- 



AMPUTATIONS OF THE HAND. 



477 



Fig. 373. 



carpal bones, which do not communicate with the others 
and with the synovial sacs. 

The incisions for the removal of the metacarpal bones 
are the same as for the removal of a finger at the meta- 
carpophalangeal joint, the incision being prolonged back- 
ward as far as necessary over the dorsal surface of the 
bone. (Fig. 371, D.) After the metacarpal bone has 
been bared for a sufficient distance, it is cut through with 
bone-pliers or disarticulated, and the distal end is raised 
from its bed and carefully separated from the soft parts, 
care being taken to avoid injury of the 
structures of the palm of the hand. 

In amputating the fifth metacarpal 
bone the incision should be made along 
the inner border of the hand and carried 
down to the bone between the skin and 
the abductor minimi digiti muscle. (Fig. 
373.) The lower end of the incision 
passes over the knuckle to the web of the 
finger, and backward under the palmar 
surface to join the first incision. 

Amputation of the entire thumb with 
its metacarpal bone is effected by making 
an oval flap from the palmar surface ; in 
the case of the left thumb the joint may 
be opened by an oblique incision on the 
dorsal surface of the hand, beginning a 
little in front of the joint and being car- 
ried down to the web between the thumb 
and forefinger; the palmar flap is then 
made by thrusting the knife upward to its point of en- 
trance and cutting downward and outward. In amputat- 
ing the right thumb with its metacarpal bone it is better 
to make the palmar flap first by transfixion, the dorsal 
flap being made subsequently. 

Amputation of the hand at the carpo-metacarpal joint is 
occasionally performed, or between the rows of carpal 
bones; but is not as a rule to be recommended, as the 
carpal bones are apt subsequently to become diseased and 

21* 




Incision for re- 
moval of the fifth 
metacarpal bone. 
(Smith.) 



478 AMPUTATIONS. 

require removal; it is therefore better to amputate at the 
radio-carpal joint. 

Amputations at the Wrist. 

Circular Method. 

The skin of the forearm near the wrist being retracted 
by an assistant, a circular incision of the skin and cellular 
tissue is made half an inch below the point of the styloid 
process of the radius. (Fig. 371, G.) The skin and 
cellular tissue are next dissected back as far as the joint, 
which is opened and the disarticulation is completed. 

Antero-posterior Flap Method. 

This method is also employed in amputations at the 
wrist-joint ; an incision curved downward is made on the 




Amputation at the wrist. (Erichsen.) 



back of the hand from one styloid process to the other ; 
the hand being flexed the tendons are divided and the 
joint opened, and the palmar flap, which should extend as 



AMPUTATIONS OF THE FOREARM. 479 

far as the base of the metacarpal bones, is cut from within 
outward. (Fig. 374.) Amputation at the wrist is some- 
times performed by cutting a single flap from the palm, 
the joint being opened by a transverse incision on the back 
of the hand from one styloid process to the other. 

Lateral Flap Method. 

This method (Fig. 371, H) is also sometimes employed 
in amputation at the wrist, and may be employed with 
advantage in cases of laceration of the hand, in which the 
injury to the tissues prevents the formation of the flaps 
used in the other methods of amputation. 

Amputations of the Forearm. 

The forearm may be amputated by the circular or flap 
methods, or by making rectangular flaps (Teale's method). 

Circular Method. 

At the lower portion of the forearm the circular method 
of amputation is to be preferred. A circular incision of 
the skin and cellular tissue is made and a cuff is dissected 
up, the muscles and interosseous membrane being cut 
through ; a three-tailed retractor is next applied and the 
bones are divided with a saw. 

Mixed Method. 

Amputation of the forearm by the mixed method, which 
consists in first dissecting up two antero-posterior oval 
flaps of skin and cellular tissue and then dividing the 
muscles by a circular incision, is also a satisfactory opera- 
tion. (Fig. 375.) 

In amputation at the upper portion of the forearm, 
antero-posterior or lateral flaps, cut from without inward 
or by transfixion, or rectangular flaps may be made with 
advantage. 



480 AMPUTATIONS. 

Fig. 375. 




Amputation of the forearm by the mixed method. (Bryant.) 

The principal vessels requiring the application of liga- 
tures in amputations of the forearm are the radial, ulnar, 
and interosseous arteries. 



Amputations at the Elbow. 

The methods of amputation employed at the elbow are 
the anterior flap, lateral flap, and circular. 

Anterior Flap Method. 

A flap three inches in length with its base parallel to 
and half an inch below the condyles of the humerus, is 
cut either by transfixion or from without inward. The 
joint is next opened and the lateral ligaments divided. 
The olecranon is then exposed and the attachment of the 
triceps separated and a posterior flap is cut from without 
inward, or from within outward, a little below the line of 
the condyles. (Fig. 376, A.) 

Lateral Flap Method. 

In amputation at the elbow-joint lateral flaps may be 
employed, cut either from without inward or by trans- 
fixion. (Fig. 376, B.) An external flap three inches in 
length is made on the outer side of the arm, starting from 
a point a finger's breadth below the bend of the elbow, by 
transfixion or by cutting from without inward ; a shorter 
internal flap is next cut in the same manner, and the joint 
is opened and the disarticulation is effected. (Fig. 377.) 



AMPUTATIONS OF THE ARM. 



481 



Circular Method. 

An incision dividing the skin and cellular tissue is 
made around the limb three inches below the line of the 



Fig. 376. 



Fig. 377. 




Amputation at the elbow- 
joint. A. Anterior flap 
method. B. External flap 
method. C. Circular method. 

(Stimson.) 




Lateral flap method of amputation at the elbow- 
joint. (Smith.) 



Fig. 878. 




Circular amputation at the elbow. 
(Smith.) 



condyles of the humerus (Fig. 376, 0), the skin is dis- 
sected up and a circular incision made through the mus- 
cles, the joint is opened and the disarticulation is effected. 
(Fig. 378.) 

Amputations of the Arm. 

The arm may be removed at any point below the attach- 
ment of the muscles at the axilla, by either the circular, 
flap, oval, or modified circular methods. 



482 AMPUTATIONS. 

Circular Method. 

This operation is usually employed in removing the arm 
in its lower third : a circular incision of the skin and 
muscles is first made, and when the cuff has been dissected 

Fig. 379. 




Circular amputation of the arm. 

up a circular division of the muscles is made, and after 
applying the retractor the bone is sawed through. (Fig. 
379.) 

Flap Method. 

From the central position of the bone in the arm, the 
flap method in amputating the arm is preferred by many 
operators. The arm being grasped by the hand the point 
of a medium-sized amputating knife is thrust through the 
arm so as to pass over the humerus and make its exit at a 
corresponding point in the skin on the opposite side ; a 
flap of sufficient length is cut from within outward. The 
knife is next passed behind the bone and a posterior flap 
is cut in the same manner (Fig. 380) ; the bone is next 
cleared of muscular tissue, the flaps are retracted and it is 
divided with a saw. 

Lateral flaps may be made in this amputation in the 



AMPUTATIONS OF THE ABM. 

Fig. 380. 



483 




Amputation of the arm by flap operation. (Bryant.) 

place of the anteroposterior flaps, and they are cut from 
within outward in the same manner. 

Oval, or Modified Oval Method. 

This method of amputating the arm is also employed 
with advantage. An oval flap of skin and cellular tissue 

Fig. 381. 




Esmarch's strap applied in high amputation of the arm. (Smith.) 

is made and dissected up, and the muscular tissue is 
divided by a circular incision. Or two oval flaps of skin 



484 



AMPUTATIONS. 



and cellular tissue are cut and dissected up, and the mus- 
cles are next divided by a circular sweep of the knife. 

In all amputations of the arm it is well to remember the 
possibility of a high division of the brachial artery, and to 
see that the abnormal vessel is properly secured, if present. 

In high amputations of the arm there is sometimes not 
room enough to apply Esmarch's strap or a tourniquet to 
the arm itself to control the hemorrhage during the opera- 
tion, and in such cases the strap may be passed from the 
axilla around the outer end of the clavicle, as is done to 
control the bleeding during amputation at the shoulder- 
joint. (Fig. 381.) 



Amputations at the Shoulder- joint. 

Several methods of operation are employed in ampu- 
tating at the shoulder-joint, such as the oval method, or 

Fig. 382. 




Amputation at the shoulder-joint. A. Oval, or Larrey's method. 
B. Double-flap, or Lisfranc's method. (Stimson.) 

Larrey's method, flap method, Lisfranc's, or Dupuytren's 
method, and Spence's method. (Fig. 382.) The control 



AMPUTATIONS AT THE SHOULDER-JOINT. 485 

of the bleeding from the axillary artery during the opera- 
tion is a matter of the first importance, and it may be 
arrested by pressure made upon the subclavian artery, as 
it crosses the first rib, with the thumb, or the padded 
handle of a large key, or by the fingers of an assistant 
grasping the axillary flap and compressing the vessel after 
the head of the bone has been disarticulated, or by the use 
of an elastic strap applied around the axilla and shoulder. 
(Fig. 381.) Wyeth's pins may also be employed with an 
elastic tube or strap to control bleeding during amputa- 
tion at the shoulder-joint. The anterior pin is passed 
through the anterior fold or the axilla, and is brought out 
in front of the acromion, the posterior pin is passed through 
the posterior fold of the axilla and is brought behind the 
acromion, the rubber strap or tube is then wrapped around 
the shoulder behind the pins and controls the hemorrhage 
during the operation. 

Oval, or Larrey's Method. 

In this method of amputation the point of the knife is 
entered just below the acromion process and a deep in- 
cision three inches in length is made down to the head of 
the bone along the axis of the arm ; from the middle of this 
incision two others are made obliquely downward to the 
points where the anterior and posterior folds of the axilla 
end in the tissues of the arm ; the latter incision should 
be only deep enough to divide the skin and superficial 
fascia. The flaps are then dissected up until the head of 
the bone is well exposed, and, after opening the capsule 
and dividing the muscles, inserted into the neck and 
tuberosities of the humerus, which division may be 
facilitated by rotating the head of the bone outward and 
inward, the disarticulation is effected by adducting the 
elbow; the knife is next passed downward behind the 
bone and made to cut outward in the line of the cutaneous 
incisions — an assistant controlling the artery before it is 
divided by grasping the axillary tissues behind the knife 
with his fingers. 



486 



AMPUTATIONS. 

Fig. 383. 




Amputation at the shoulder-joint by Larrey's method. 

Flap, or Dupuytren's Method. 

In this method of amputation at the shoulder-joint the 
flaps may be cut either by transfixion or from without 
inward ; the large flap embraces the greater part of the 
deltoid muscle, and the smaller or short flap is cut from 
the inside of the arm after the head of the bone has been 
disarticulated. When cut by transfixion, the point of the 
knife should be entered an inch in front of the acromion 
process and pushed across the outer aspect of the head of 
the humerus, and should be brought out at the posterior 
fold of the axilla ; the knife is made to cut downward 
until a large deltoid flap is formed. This flap is turned 
up, and the head of the bone is disarticulated ; the knife 
being placed behind it, a short flap is formed, keeping 
close to the bone, so that the vessel is divided with the 
last cut of the knife. (Fig. 384.) An assistant should 



AMPUTATIONS AT THE SHOULDER- JOINT. 487 



ccmtrol the vessel by grasping the axillary tissues with his 
fingers behind the knife. 



Fig. 384. 




Fig. 385. 



Amputation at the shoulder-joint. Dupuytren's method. (Bryant.) 

Double Flap, or Lisfranc's Method. 

In this method of amputation at the shoulder-joint, the 
point of the knife is entered at the outer side of the cora- 
coid process, and is carried across 
the outer aspect of the head of the 
humerus and brought out a little 
below the posterior border of the 
acromion process, and a long flap 
is cut downward. This flap is 
turned up and the attachments 
of the head of the bone are 
divided and it is disarticulated. 
The knife is again entered behind 
the bone, and a long posterior 
flap is cut from within outward. 
(Fig. 382, B.) 

Spence's Method. 
In this method of amputation 

. , i i -i-i • ' j. • • • Amputation at the shoulder- 

at the shoulder-joint an incision ]oint P Spence > smethod . (Stim . 
is made down to the head of the S0N .) 




488 AMPUTATIONS. 

humerus immediately in front of the coracoid process, 
and is continued downward through the clavicular fibres 
of the deltoid and the pectoralis major muscles until the 
attachment of the latter to the humerus is reached. (Fig. 
385.) The incision is now carried backward to the poste- 
rior fold of the axilla. A second incision, including only 
the skin and cellular tissue, is next made from the ante- 
rior portion of the first incision across the inside of the 
arm to meet the incision on the outer part. The outer flap 
thus formed is turned up and the head of the bone is dis- 
articulated. The operation is completed by dividing the 
remaining tissues on the axillary aspect. 

Many other methods of removing the arm at the 
shoulder-joint have been devised and employed, including 
the circular method. 

Amputation above the Shoulder- joint. 

Fig. 386. 




. ft 

Amputation of arm, scapula, and clavicle (dotted line representing posterior 
incision). (Treves.) 

This form of amputation consists in the removal of the 
arm with a part or the whole of the scapula and sometimes 
a portion of the clavicle. 



AMPUTATIONS OF THE FOOT. 



489 



As this form of amputation is required in cases in which 
the laceration of the parts has passed beyond the shoulder- 
joint, or in cases of growths involving the tissues beyond 
the joint, no definite rule can be laid down for the in- 
cisions ; the only rule being as far as possible to make the 
incisions in such a manner that the least possible amount 
of skin is sacrificed, so that a sufficient covering for the 
wound can be obtained. 



Amputations of the Foot. 
Amputations of the Toes. 



Fig. 388. 



Fig. 387. 





Relations of web and metatarso- 
phalangeal joints of toes. (Stim- 
son.) 



Incisions for amputation of toes and 
metatarsal bones. (Stimson.) 



490 AMPUTATIONS. 

The phalanges of the toes may be removed in the same 
manner as those of the fingers. It is better to amputate 
at the metatarsophalangeal articulations than to attempt to 
remove them at the joints in front of this articulation, 
except in the case of the great toe, as the preservation of a 
portion of a toe is rather a discomfort than an advantage, 
except in the instance mentioned. All incisions should 
be made so that the resulting cicatrix does not occupy the 
plantar surface, and it is well to remember that the web 
of the toes is considerably below the position of the meta- 
tarso-phalangeal joint. (Fig. 387.) 

The toes are usually removed by an incision on the 
dorsal surface a little above the joint, which is carried 
down the bone for about an inch and then diverges into 
the web, and is carried under the toe and back on the 
other side to the point of divergence. (Fig. 387.) 

Amputation of Two Adjoining Toes. 

The dorsal incision should be made in the inter- 
metatarsal space just above the level of the joint (Fig. 
388, B) and carried down to the beginning of the web ; 
then over the toe to the beginning of the adjoining web, 
then under the plantar surface of both toes in the line of 
the digito-plantar fold, through the web and back to the 
point of divergence. 

Amputation of the Great Toe. 

This may be accomplished by means of the racket-shaped 
incision employed in amputation of the other toes or by 
means of a lateral flap. In the latter case the knife is 
made to enter the joint by cutting through the commissure, 
and the operation is completed by carrying the knife 
through the joint and along the outer side of the bone, 
forming a flap of the required size. (Fig. 389.) 

In this amputation a short dorsal flap and long plantar 
flap may be employed, or a long internal flap may be 
used. 



AMPUTATIONS OF THE METATARSAL BONES. 491 

Amputation of All the Toes. 

To amputate all the toes, make a dorsal incision from 
the head of the fifth to the head of the first metatarsal 
bone ; the incision should be a curved one passing just in 
front of the joints. (Fig. 390.) Dissect up the flap and 




Fig. 390. 




Amputation of the great toe. 
(Smith.) 



Incision for amputation of all the 
toes. (Smith.) 



open the joints, dividing the lateral ligaments, and pass 
the knife behind the phalanges and cut a flap from the 
plantar surface. 

Amputations of the Metatarsal Boxes. 

It is better in these amputations to leave the tarsal head 
of the metatarsal bone in place and divide the bone, or, in 
other words, to do an amputation in continuity to prevent 
opening up the tarsal articulations. 



Amputation of the Metatarsal Bone of the Great Toe. 

The incision begins upon the dorsal surface of the meta- 
tarsal bone, a little below the point at which the bone is 



492 



AMPUTATIONS. 



to be divided, and is carried down below the metatarso- 
phalangeal joint, then diverges and passes under the toe 
and comes back again to the point of divergence. (Fig. 
388, C.) The bone is exposed and cut through with cut- 
ting forceps, and is then lifted up and dissected loose from 
the tissues. (Fig. 391.) 



Fig. 391. 




Amputation oi the great toe and first metatarsal bone. (Smith ) 

Amputation of the Fifth Metatarsal Bone. 

The incision for the removal of the fifth metatarsal bone 
is made over the bone a little below the metatarso-tarsal 
articulation, and is carried down and curved around the 
toe (Fig. 388, D), and after the bone is exposed by dis- 
secting back the flaps, it is divided, or the joint is opened 
and it is dissected out. 



Amputation Through the Metatarsal Bones. 

In performing this amputation an incision is made 
across the dorsum of the foot, and a short dorsal flap is 
dissected up ; the metatarsal bones are next divided with 
a saw and a long plantar flap is cut from within outward 
by entering the knife behind the ends of the bones. 



AMPUTATION OF THE METATARSAL BONES. 493 

Tarso-metatarsal Amputations. 

In all amputations of the foot involving the tarsus the 
surgeon should be thoroughly familiar with the anatomy 
of the foot and the surgical landmarks of the different 
articulations. I shall refer to those laid down by Mr. 
Bryant, which are as follows : 



Fig. 392. 



Fig. 393. 





Surgical guides to the foot as expressed 
by anatomy. (Bryant.) 



Incision for — A. Lisfranc's am- 
putation. B. Chopart's ampu- 
tation. (Stimson.) 



" On the inner side of the foot, not far from the inner 
malleolus, the tubercle of the scaphoid (Fig. 392, A) is to 
be felt as a marked prominence ; about one-half an inch 
in front of this will be found the articulation with the 

22 



494 AMPUTATIONS. 

cuneiform bone (if), and one inch in front of this the joint 
which the surgeon will have to open in Lisfranc's or Hey's 
operation ((7) ; just above the tubercle of the scaphoid will 
be found the articulation with the astragalus, the line of 
Choparfs amputation (i)). On the outer side of the foot, 
one inch below the external malleolus, a sharply defined 
projection will always be felt, which is the peroneal tuber- 
cle (E) ; one-half an inch in front of this will be found the 
joint which separates the os calcis from the cuboid (F), 
this joint forming the outer circle to Chopart's amputa- 
tion. Half an inch in front again, or one inch from the 
tubercle, the prominence of the fifth metatarsal bone is 
always to be felt (H), the line above this prominence 
indicating the articulation with the cuboid bone, which 
forms the outer boundary of the incision for Hey's or 
Lisfranc's amputations." 

Tarso-metatarsal Amputation (Lisfranc's). 

The incision for this amputation is a curved one carried 
across the dorsum of the foot from the base of the fifth to 
the base of the first metatarsal bone. (Fig. 393, A.) The 
incision should involve the skin only, its centre lying half 
an inch or more below the centre of the line of the articu- 
lations, and it should begin and end at the sides of the 
foot at their junction with the sole. A plantar flap should 
be marked out by a curved incision crossing the sole of 
the foot near the origin of the toes, starting and ending at 
the same points as the dorsal incision. 

The dorsal flap is next dissected back to the line of the 
articulations ; the tendons, muscular fibres, and fascia being 
divided, the joints between the tarsal and metatarsal bones 
are opened with a stout, narrow-bladed knife. (Fig. 394.) 
Difficulty is sometimes experienced in opening the joint 
between the head of the second metatarsal bone and the 
second cuneiform bone, which occupies a position higher on 
the foot than the other articulations. The disarticulation 
may also be facilitated by forcibly depressing the anterior 
portion of the foot. After all the joints have been opened, 



AMPUTATIONS OF THE METATARSAL BONES. 495 
Fig. 394. 
f 




Amputation at tarsometatarsal joint (Lisfranc's). 

the knife is passed behind the ends of the metatarsal bones, 
and a plantar flap is cut from within outward, following 
the line of the incision previously marked out. The 
plantar flap may be cut from without inward if preferred. 

Tarso-metatarsal Amputation (Hey's). 

The line of incision and the steps of this operation are 
similar to those in Lisfranc's amputation, with the excep- 
tion that Hey sawed off the projecting portion of the 
internal cuneiform bone after disarticulating the meta- 
tarsal bones. This modification, although it improves the 
appearance of the stump, possesses no advantages over the 
previous procedure. 

Medio-tarsal, or Ckopart's Amputation. 

In this amputation the disarticulation is through the 
joints formed by the astragalus and calcaneum behind and 
the scaphoid and cuboid in front. An incision is made 
from the tubercle of the scaphoid across the dorsum of 
the foot an inch in front of the head of the astragalus to 



496 



AMPUTATIONS. 



the lower and outer border of the cuboid. (Fig. 395, A.) 
The plantar flap is next marked out by an incision begin- 



FlG. 395. 




Line of incision for— A. Chopart's amputation. B. Syme's amputation. 
D. Section of bone in Syme's amputation. C. Subastragaloid amputation. 

(Stimson.) 

ning and ending at the same points as the first incision 
and crossing the sole of the foot four or five finger- 

FlG. 396. 




Chopart's amputation. (Bryant.) 



breadths nearer the toes. The dorsal flap is next dissected 
up, and after the tendons and fascia have been divided 



AMPUTATIONS AT THE ANKLE-JOINT 



497 



the joint is opened and a plantar flap is cut from within 
outward, following the line of the previously marked out 
plantar incision. (Fig. 396.) 

Subastragaloid Amputation. 

In this amputation all the bones of the foot are removed 
except the astragalus. An incision is made beginning an 
inch below the tip of the external malleolus, which is car- 
ried forward to the base of the fifth metatarsal bone; it is 
then carried over the dorsum of the foot to the calcaneo- 
cuboid articulation. (Fig. 395, (7.) The joints between 
the scaphoid and astragalus and between the astragalus 
and calcis are opened, and the latter bone is carefully dis- 
sected out ; the ligaments are divided and the astragalus 
only is allowed to remain in place. 

Amputations at the Ankle-joint. 
Syme's Amputation at the Ankle-joint. 

Fig. 397. 




Syme's amputation at the ankle-joint. (Skey.) 



498 



AMPUTATIONS. 



In this amputation, the foot being at a right angle to 
the leg, an incision is made from the centre of one mal- 
leolus directly across the sole of the foot to the centre of 
the opposite malleolus. (Fig. 395, B.) The tissues of the 
heel are next carefully dissected from the bone by keeping 
the knife close to the osseous surface until the tuberosity 
of the os calcis is fairly turned. The two extremities of 
the first incision are then joined by a transverse one across 
the instep, and, the joint being opened, the lateral liga- 
ments are divided to complete the disarticulation. (Fig. 
397.) The knife is next used to clear the malleoli, and 
they are next removed by the saw in the line indicated. 
(Fig. 395, D.) 

Pirogoff's Amputation at the Ankle-joint. 

In this amputation the posterior portion of the os calcis 
is retained. The incision is carried from the tip of the 

Fig. 398. 




Pirogoff's amputation. A. Cutaneous incision. B. Line of section of bones. 

(Stimson.) 



inner malleolus, over the instep, half an inch in front of 
the anterior edge of the tibia, to a point half an inch in 



AMPUTATIONS AT THE ANKLE-JOINT 499 

Fig. 




Application of saw to os calcis in Pirogoff's amputation. (Erichsen.) 

front of the tip of the outer mal- FlG - 400 

leolus; a second incision, crossing 

the sole of the foot and carried 

down to the bone, is next made. 

(Fig 398, A.) The plantar flap 

is dissected back for a quarter of 

an inch, the joint is opened by 

dividing the lateral ligaments, and 

the astragalus is disarticulated, and 

the malleoli are exposed. A narrow 

saw is next applied to the upper 

and posterior part of the calcaneum 

behind the astragalus, and it is 

divided obliquely downward in the 

line of the plantar incision. (Fig. 

399.) The malleoli and a thin slice 

of the tibia are next removed with 

the saw as in Syme's amputation. 

(Fig. 395, D.) Some surgeons do 

not remove the malleoli, but press the sawed surface of 

the os calcis between them when it is possible to do so. 




Union between calcaneum 
and tibia in Pirogoff's ampu- 
tation. (Hewson ) 



5U0 AMPUTATIONS. 

The position of the os calcis in relation to the tibia after 
union has occurred is shown in Fig. 400. 

Roux's Amputation at the Ankle-joint 

In this method of amputation an incision is made at the 
outer edge of the tendo-Achillis, a little above its inser- 
tion, which is carried forward under the outer malleolus, 
and across the instep half an inch in front of the anterior 
edge of the tibia, and back to a point just in front of the 
inner malleolus ; the incision is carried from this point 
downward and partly across the sole of the foot, and then 
back to the point of origin of the original incision. (Fig. 
401.) The flaps are dissected up for a short distance, the 
ankle-joint is then opened, the disarticulation is effected, 
and the internal flap is carefully dissected from the bones, 

Fig. 401. 




Incision in Roux's amputation. 

Other methods of amputation of the foot are sometimes 
employed ; such, for instance, as that advocated by Hancock, 
who has combined Pirogoff's amputation with the sub- 
astragaloid method, bringing the sawed surface of the os 
calcis in contact with a transverse section of the astragalus. 

Hancock has advocated the propriety of amputating in 



AMPUTATIONS OF THE LEG. 501 

the foot without regard to the position of the tarsal joints, 
cutting the flaps of sufficient length and dividing the bones 
with a saw. 

Tripier has also modified the subastragaloid amputation 
by leaving the upper part of the calcaneum, which he saws 
through on a level with the sustentaculum tali, and at right 
angles to the axis of the leg ; the external incisions are 
made as in Chopart's amputation. 

In the method advocated by Mikulicz the astragalus and 
calcaneum are removed, the ends of the tibia and fibula 
are sawed off, and the sawed surface of the scaphoid and 
cuboid are approximated to these, the stump resulting re- 
sembling the foot of pes equinus. 

Amputations of the Leg. 

The leg may be amputated at its lower, middle, or upper 
third, the rule being to save as much of the limb as pos- 
sible, but as regards the application of prothetic apparatus, 
I think the stumps resulting from amputations in the 
middle and upper thirds will be found more satisfactory. 
It is well also in sawing the bones to divide the fibula at 
a slightly higher point than the tibia. 

Amputation of the Lower Third of the Leg. 

At this position the leg may be amputated by the cir- 
cular, modified circular, or elliptical method. 

Circular Method. 

A circular incision is made through the skin and con- 
nective tissue just above the malleoli, and the cuff is dis- 
sected up for a sufficient distance, and a circular incision 
of the tendons and muscles is next made, and the tissues 
being retracted the bones are divided with a saw. 

22* 



502 



AMPUTATIONS. 



Modified Circular Method. 

In this method of amputation of the leg a circular in- 
cision of the skin and connective tissue and two short 



Fig. 402. 



Fig. 403. 





Fig. 402.— Amputation of the leg. A. Modified circular method. B. Rectangu- 
lar flap, a Antero-posterior flap. The dotted lines indicate the levels at which 
the bones are to be sawn through. (Stimson.) 

Fig. 403.— Amputation of the leg. A. Long anterior flap. B. Supra-malleolar 
long posterior flap. 0. At upper third. (Stimson.) 



AMPUTATIONS OF THE LEG. 



503 



lateral incisions are made. The flaps are then dissected up 
to the end of the incisions, and a circular division of the 
muscles is next made. (Fig. 402, A.) Or oval skin flaps 



Fig. 404. 




Oval skin flaps with circular division of the muscles. 

are made and dissected up, and the tissues are next divided 
down to the bone by a circular incision and the bones are 
divided with a saw 7 . (Fig. 404.) 

Elliptical Method. 

In this method of amputation the incision is in the form 
of an ellipse ; its lower end crosses the heel below the inser- 
tion of the tendo Achillis and the upper end of the inci- 
sion is about an inch above the anterior articular edge of 
the tibia. (Fig. 403, B.) 

Long Anterior Flap Method. 

An anterior flap equal in length to the diameter of the 
leg at its base is marked out by a curved incision through 
the skin beginning at the posterior edge of the tibia on 
the inner side, a little below the point at which the bones 
are to be divided, and is carried over the leg to a point 
directly opposite over the fibula. (Fig. 403, A.) The 
anterior muscles are divided transversely half an inch 
above the lower end of the flap and are dissected from the 
bone to the base of the flap. 

The posterior flap is then made by entering the knife 
behind the bones at the point of the original incision and 
cutting directly outward. 



504 AMPUTATIONS. 

Long Anterior Rectangular Flap Method. (Teale.) 

In this method of amputation of the leg an incision 
equal in length to half of the circumference of the leg is 
made from the point at which the bones are to be divided 
on one side of the leg, and is carried across the limb and 
back upon the opposite side to a point opposite the point 
of starting. The flap thus marked out is dissected up to 
its base and a posterior flap of one-fourth the length is next 
cut by a transverse incision down to the bones, and is dis- 
sected back to the line of the origin of the first incision. 
(Fig. 402, B.) The long flap is next doubled back and 
its edges secured to the posterior flap, or the long flap may 
be cut from the posterior surface of the leg and the short 
flap from the anterior surface. 

Antero-posterior Flap Method. 

A long anterior flap including half of the circumference 
of the limb may be cut from without inward, composed of 
skin, connective tissue, and muscles, and a short posterior 
flap cut from within outward may also be employed. This 
method is often employed in amputations in the upper 
portion of the leg. (Fig. 402, O.) 

Lateral Flap Method. 

In the lower and middle thirds of the leg the method 
of amputation by means of lateral skin flaps may be em- 
ployed with advantage. In this method an incision is 
made over the spine of the tibia, and an oval flap em- 
bracing one-half of the circumference of the leg, composed 
of the skin and connective tissue, is dissected up ; starting 
from the same point a similar flap is formed on the opposite 
side of the leg and dissected up ; the muscles at the upper 
extremity of the flaps are next divided by a circular incision 
and the bones are divided with a saw. 



AMPUTATIONS AT THE KNEE-JOINT 505 

External Flap Method. (Sedillot.) 

In this method of amputation of the leg the point of the 
knife is entered a finger's breadth external to the spine of 
the tibia and carried outward, grazing the fibula, and is 
brought out as far as possible to the inner side ; a flap 
three or four inches in length is then cut from within out- 
ward ; the extremities of the incision are next united by 
an incision across the inner side of the limb involving the 
skin only ; any remaining muscular tissue is next divided 
and the bones are sawed. The long external flap is then 
brought over the ends of the bones and fastened to the 
edges of the incision on the inner side of the limb. Prof. 
Ashhurst modifies this operation by cutting the long ex- 
ternal flap from without inward, and makes also a short 
internal flap in the same manner. By either method the 
resulting stump is a good one, with the ends of the bones 
covered by the tissues of the external flap. 



Amputations at the Knee-joint. 

Amputations at the knee-joint may be done either by 
the circular or elliptical incision or by means of flaps, and 
may consist in simple disarticulations or sections through 
the condyles of the femur. 

Elliptical or Oval Method. 

In this operation an incision crossing the spine of the 
tibia five finger-breadths below the lower extremity of the 
patella, is carried around the back of the leg three finger- 
breadths higher than in front ; the tissues on the front of 
the leg are dissected up until the tendon of the patella is 
exposed ; the leg is then flexed, and the ligament of the 
patella is divided ; the capsular ligament and the lateral 
and crucial ligaments are next severed, care being taken 
not to injure the popliteal vessels with the point of the 
knife. The tibia is next drawn forward and the knife is 



506 



AMPUTATIONS. 



Fig. 405. 



passed behind its posterior border, and the remaining soft 
parts are divided from within outward. 

Anterior Flap Method. 

In this method of amputation a long cutaneous flap is 
formed ; the incision beginning half an inch below the 

articulation is carried five inches 
below the patella ; crossing the 
anterior surface of the leg it is 
carried back to the condyle of the 
femur on the opposite side. This 
flap is dissected up and the liga- 
ment of the patella is divided, 
and the disarticulation is effected. 
A short posterior flap, uniting the 
anterior incision one inch below 
its extremities, is next cut by 
transfixion or from without in- 
ward. (Fig. 405, A.) The pa- 
tella is not removed. 



Amputation through the Condyles 
of the Femur. 

In this amputation, which is 
known as Garden's amputation, 
an anterior flap, whose lower ex- 
tremity is three finger- breadths 
below the patella, is cut and the 
disarticulation is effected, and the 
posterior soft parts are divided. 
The patella is removed, and the 
condyles next sawed through just 
above the edge of the articular 
cartilage. (Fig. 405, B.) 

Lateral Flap Method. 

In this operation an incision 
is made just below the patella, 




Amputations at the knee-joint 
and lower third of the thigh. A. 
Long anterior flap. B. Ampu- 
tation through condyles. C. 
Modified flap at lower third of 
thigh. (Stimson.) 



AMPUTATIONS OF THE THIGH. 



507 



which is carried down the spine of the tibia for three 
inches, and is then carried backward to the middle of the 
leg to a point opposite the beginning of the incision ; a 



Fig. 406. 




Amputation at the knee-joint by lateral flaps. (Smith.) 

similar flap is cut on the opposite side of the leg, and the 
flaps are dissected up to the line of the articulation. When 
this point is reached the joint is opened and the disarticu- 
lation is effected. The patella is not removed. (Fig. 406.) 

GrrittVs Amputation at the Knee-joint 

In this operation a long rectangular anterior flap is 
first cut and dissected up, and after the disarticulation 
has been effected the skin covering the posterior surface 
of the knee is cut from within outward. The condyles 
of the femur are next removed by a saw above the edge 
of the articular cartilage, and the articular surface of the 
patella is removed by the saw or cutting forceps. The 
patella is next brought down, so that its sawed surface is 
in contact with the sawn surface of the condyles, and the 
flaps are brought together. (Fig. 407, A) 



Amputations of the Thigh. 
Modified Flap Method. 

Two semilunar flaps of skin and connective tissue, the 
upper extremities of which are several inches above the 



508 



AMPUTATIONS. 



condyles of the femur, are cut and dissected up, and the 
muscles are next divided by a circular incision, and the 
bone is cut through with the saw. (Fig. 405, (7.) 

Long Anterior Flap Method. 

In this operation an incision is made on the anterior 
aspect of the thigh, marking out a flap whose length is 

Fig. 407. 




A. Gritti's amputation at the knee. A'. Lines of division of the bones. 2?. 
Amputation of the thigh, long anterior flap. B'. Division of the bone. C. Am- 
putation at the lower third of the thigh. (7. Division of the bone. D. Dis- 
articulation at the hip-joint. 



AMPUTATIONS OF THE THIGH. 509 

equal to one-third, and whose width at its base is equal to 
two-thirds, of the circumference of the limb. The anterior 
muscles are next divided obliquely upward and backward, 
so that the flap shall not be too thick, and the posterior 
muscles are cut transversely and the bone is divided with 
a saw. (Fig. 407, B.) 

Amputation in the lower third of the thigh may also be 
effected by employing a long anterior and short posterior 
flap. The anterior flap is cut, its lower extremity extend- 
ing down to the lower edge of the patella, and after dis- 
secting up the skin and cellular tissue to the upper 
extremity of the patella, the muscles are cut obliquely up 
to the point at which the bone is to be divided. A short 
posterior flap is next cut, and the soft parts being retracted, 
the bone is sawed through. (Fig. 407, C.) 



Amputation of the Thigh by Transfixion. 

In amputations of the thigh the flaps may also be cut 
by transfixion, either lateral or a ntero-posterior flaps being 
employed. (Fig. 408.) 

Fig. 408. 




Amputation of thigh by flaps cut by transfixion. 



510 



AMPUTATIONS. 



Amputation of the Thigh through the Trochanters. 

When, for any reason, it is inadvisable to amputate at 
the hip-joint, an amputation may be made through the 
trochanters, a long anterior and short posterior flap being 
employed with a circular division of the muscles. 



Amputations at the Hip-joint. 



In amputations at the hip-joint it is important that 
provision be made for the control of hemorrhage during 
the operation, and this is accomplished by the use of an 
abdominal tourniquet (Fig. 409), or by the use of Davy's 
lever making compression upon the common iliac artery 
from the rectum, or by compression of the femoral artery 

Fig. 409. 




Abdominal tourniquet. 



by the fingers of an assistant, or by the preliminary liga- 
tion of the femoral artery just below Poupart's ligament. 
Esmarch's elastic strap may also be employed for the con- 



AMPUTATIONS AT THE HIP-JOINT. 51 1 

trol of bleeding during amputation at the hip-joint, the 
strap being applied in such a manner that it occupies the 
position of the turns of a spica bandage of the groin. 
(Fig. 410.) 

Dieffenbach and Wyeth, to avoid hemorrhage, make 
first a circular amputation in the continuity of the thigh, 
and after controlling the hemorrhage disarticulate the 
head of the femur and remove it ; Jordan and Senn dis- 

Fig. 410. 




Esmarch's elastic strap applied to control hemorrhage during 
amputation at the hip-joint. 

articulate the head of the bone first through an external 
incision and control the bleeding before the amputation is 
completed by passing an elastic tourniquet around the soft 
parts above the point where they are to be divided. 

The methods of amputation at the hip-joint are the 
oval, antero-posterior flap, and lateral flap, and modified 
circular methods. 

Oval Method. 

This is performed by entering the point of a strong 
knife into the tissues below the anterior superior spinous 



512 



AMPUTATIONS. 



process of the ilium and making two oblique incisions, 
one forward and downward and the other backward, both 
incisions meeting on a transverse line on the inner side 
of the thigh. The muscles are next divided on a little 
higher line, and when the joint is exposed disarticulation 
is effected from the outer side and any remaining tissue is 
divided. 

Antero-posterior Flap Method. 

In this method the point of a long amputating knife is 
thrust into the tissues about two finger-breadths below the 
anterior superior spinous process of the ilium, and is pushed 
through the tissues grazing the hip-joint, and is brought 
out on the opposite side of the thigh close to the junc- 
tion of the scrotum. The knife is next carried downward 



Fig. 411. 




Amputation at the hip-joint by antero-posterior 



(Holmes.) 



close to the bone and an anterior flap of sufficient length 
is cut from within outward. This flap is held up by an 



AMPUTATIONS AT THE HIP-JOIXT. 51 3 

assistant and the head of the bone is disarticulated, and 
the knife being passed behind the bone, a posterior flap of 
equal length is cut from within outward. (Fig. 411.) 

Guthrie? s method of amputation at the hip-joint consists 
in cutting the flaps from without inward, a smaller knife 
being used for this purpose and the posterior flap being 
cut first. 

Modified Circular Method. 

In this operation short anteroposterior flaps of skin 
and connective tissue are cut and dissected up, and the 
muscles are divided by a circular incision on the level of 
the joint, and the disarticulation of the head of the femur 
is next effected. 

Lateral Flap Method. 

In this operation two flaps are cut from the inner and 
outer side of the thigh by transfixing, or by cutting from 

Fig. 412. 




Amputation at the hip-joint "by external and internal flaps. (Bryant.) 

without inward and exposing the joint, which is opened 
and the disarticulation of the head of the femur is effected 
as in the previous methods. (Fig. 412.) 

Wyeth's Method of Amputating at the Hip-joint. 

In amputating at the hip-joint by this method the hip 
to be operated upon is brought well over the edge of the 



514 AMPUTATIONS. 

table and an Esmarch bandage is applied to the limb, and 
two stout steel mattress needles twelve or fourteen inches 
in length are required ; the point of one of these needles 
is passed through the skin one and a half inches below 
and slightly to the inner side of the anterior superior spine 
of the ilium and carried through the tissues about half- 
way between the great trochanter and the spine of the 
ilium external to the neck of the femur, and its point is 
made to emerge just behind the trochanter; the second 
needle is made to enter the skin an inch below the crotch, 
internal to the saphenous opening, and its point is made 
to emerge about an inch and a half in front of the tuber 

Fig. 413. 




Pins inserted and tube applied. 

ischii. The points of the needles are next protected with 
corks, and a long piece of rubber tubing or an Esmarch 
elastic strap is wound tightly five or six times about the 
limb above the fixation needles. (Fig. 413.) The Esmarch 
bandage should then be removed and a circular incision 
of the skin and cellular tissue should be made five inches 
below the constricting band; this cellulo-cutaneous cuff* 
should next be reflected to the level of the trochanter 
minor : a circular division of all the muscles should next 



AMPUTATIONS AT THE HIP-JOINT. 



515 



be made at this point and the bone divided with a saw 
The large vessels should next be secured, and after this has 
been done the rubber tube should be removed and any 
vessels which bleed should be tied ; all remaining attach- 
ments of the femur and the capsule should be opened and 
the head of the bone disarticulated. A drain should be 



Fig. 414. 




Limb amputated and bone sawn. (Wyeth.) 

next introduced and the edges of the flaps brought together 
vertically. 



PART VII. 

EXCISIONS OR RESECTIONS. 



Excision of a joint implies the partial or complete re- 
moval of the articular surface of the bones making up the 
joint. The term resection is sometimes used as synony- 
mous with excision, but is usually employed to indicate 
the removal of a portion or the whole of the shaft of one 
of the long bones. Excisions or resections of joints and 
bones may be required on account of injury, disease, or 
anchylosis of a joint in faulty position. In the operation 
of excision of the joint the incision should be free enough 
to permit of an inspection of the diseased portions of the 
joint, and it is preferable to remove the diseased articular 
surface of the bone with a saw ; small areas of diseased bone 
may be removed with the curette or gouge forceps. In per- 
forming excisions of joints in young subjects care should 
be taken to see that the epiphyseal cartilage is not en- 
croached upon, for if this is removed the subsequent 
growth of the limb is interfered with. The result desired 
in cases of excision of joints, in addition to the removal 
of the diseased tissue, varies somewhat with the joint in- 
volved; for instance, in a knee-joint anchylosis is desired ; 
in the shoulder, hip, elbow, and wrist, we wish to obtain a 
movable false joint ; when the latter condition is desired 
after excision, care should be exercised not to divide mus- 
cles or tendons, and as far as possible not to interfere with 
their attachments. When anchylosis is desired the divi- 
sion of muscles or tendons is not a serious consideration ; 



EXCISIONS OB RESECTIONS, 



517 



anv injury to the principal arteries, veins, and nerves 
should always be avoided. 




Butcher's saw. 



The instruments required for the excision of joints are a 
stout scalpel (Fig. 415), probe-pointed knife, an excision 



Fig. 417. 



Narrow-bladed saw. 
Fig. 418. 




Chain saw. 



saw with reversible blade (Fig. 416), narrow-bladed saw 
(Fig. 417), or chain saw (Fig. 418), strong lion-jawed for- 



518 



EXCISIONS OB RESECTIONS. 

Fig. 419. 




Lion-jawed forceps. 
Fig. 420. 




Retractor. 
Fig. 421. 



Elevator. 
Fig. 422. 




Bone-cutting pliers. 
Fig. 423. 




Knife-bladed forceps. 
Fig. 424. 




Periosteotome. 



EXCISION OF THE SHOULDER- JOINT. 51 9 

ceps (Fig. 419), retractors (420), an elevator (421), heavy 
bone-cutting pliers (Fig. 422), knife-bladed forceps (Fig. 
423), and a periosteotome (Fig. 424). 

Excision of the Shoulder- joint. 

In excising the shoulder-joint the arm is adducted and 
rotated inward, and a straight incision is made extending 



Fig. 4'25. 




Excision of shoulder-joint : A. Regular incision. B. Supplementary. 

from the beak of the coracoid process down the arm in the 
line of the bicipital groove ; this incision may be supple- 
mented by a short, transverse incision from the upper edge 
of the first incision to the acromion process. As the in- 
cision is deepened the fibres of the deltoid muscle are 
divided in this line, and the capsule of the joint is exposed 
and divided along the outer edge of the tendon of the long 
head of the biceps muscle ; this tendon is held to one side 
and the capsule of the joint is freely opened, and the 
muscles inserted into the tuberosities of the humerus are 
divided with a probe-pointed knife and freed with an ele- 
vator ; the head of the bone can then be removed by saw- 
ing across the surgical neck of the bone with a narrow 
metacarpal saw or chain-saw, and the sawn surface of the 
humerus should then be rounded off with bone pliers. If 



520 EXCISIONS OB RESECTIONS. 

upon examination the glenoid cavity is found to be dis- 
eased, this with the neck of the scapula may be removed 
with gouge forceps or a small saw. The bone is then 
reduced and the wound is drained and closed. 

Eesection of the Humerus. 

The whole or a portion of the humerus may require re- 
section for injury or disease. The incision should be made 
upon the outer side of the bone and carried down in the 
muscular interspaces on a line with the shaft, care being 
taken to avoid injury of the musculo-spiral nerve, which, 
as it passes around the posterior surface of the humerus 
lies close to the bone between the humeral heads of the 
triceps muscle at a point corresponding to the deltoid in- 
sertion anteriorly — L e., about the centre of the shaft of 
the humerus. This nerve should be isolated and held 
aside and the bone should be exposed. After separating 
the periosteum as completely as possible, if the shaft of 
the bone is diseased, it should be removed by dividing it 
in the middle with a saw or forceps, and removing each 
fragment as far as the upper and lower epiphysis, or the 
upper or lower portion only may require removal. In 
resecting the humerus for an ununited fracture the inci- 
sion is made upon the outer surface of the arm over the 
seat of fracture, and when the latter has been exposed the 
fragments are separated, and the end of each fragment is 
removed with a saw to obtain a fresh bone surface. The 
freshened ends of the bone are then drilled and united by 
heavy silver-wire sutures, silver plates, or screws. 

Excision of the Elbow- joint. 

In excising the elbow-joint the forearm is slightly 
flexed, and a longitudinal incision is begun about two 
inches above the olecranon process and a little to its inner 
side, and carried about three or four inches down in the 
line of the ulna; the tissues are then divided down to 
bone, and the ulnar nerve is dissected from its groove be- 



RESECTION OF RADIUS AND ULNA. 



52 L 



Fig. 426. 



\ 



hind the inner condyle of the humerus and held aside by 
a retractor, the tendon of the triceps is divided and its 
attachment to the fascia and periosteum 
over the olecranon process is separated 
with an elevator or periosteotome and 
turned downward; the joint is next 
opened and the lateral ligaments are 
divided as the forearm is flexed upon 
the arm. The upper part of the ulna 
and the head of the radius are freed 
with a probe-pointed knife and are re- 
moved with a narrow-bladed saw, care 
being taken in making the section of 
the radius to divide its neck so that the 
attachment of the biceps muscle is not 
interfered with. The condyles of the 
humerus are next freed and removed 
with a saw. In freeing the bones at 
the anterior portion of the joint great 
care should be used to avoid injury of 
the brachial artery and vein and the 
median nerve. After the joint has 
been excised the bones are reduced and the wound is 
drained and closed. 



/ 



Incision for excision of 
the elbow-joint. 



Resection of the Radius and Ulna. 



The radius or ulna may be resected either entirely or 
partially by making an incision over the bone to be re- 
moved upon the back of the forearm ; the bone being ex- 
posed, the periosteum is separated with an elevator and 
the bone is divided with a saw, and each fragment is lifted 
and separated from its muscular attachments up to the 
point where it is desired to remove it. If the articular 
surface of the bone is to be removed, the disarticulation 
should be made carefully with a strong scalpel or a probe- 
pointed knife, care being taken to avoid injury of the 
vessels and nerves lying upon its palmar surface. 



522 



EXCISIONS OR RESECTIONS. 



Fig. 427 




Resection of the lower end of the radius. 

Excision of the Wrist. 

The wrist is covered on its posterior and lateral aspect 
with skin, fascia, and tendons ; the relative position of the 

Fig. 428. 




Articulations of the wrist-joint. (Lister.) 

bones entering into the articulation can be seen in the 
accompanying figure. (Fig. 428.) The wrist-joint may 



EXCISIOX OF THE WRIST. 



523 



be excised by making a dorsal incision which begins at the 
middle of the ulnar border of the second metacarpal bone, 
and is carried upward about four inches, crossing the ulnar 
edge of the tendon of the extensor carpi- radialis-brevior, 
and splitting the dorsal ligaments of the wrist between 
the tendons of the extensor secondi-internodii and the ex- 
tensor of the forefinger. The incision should be carried 
down to the bone, and the soft parts and tendons should 
be dissected loose with an elevator. By flexing the hand the 

Fig. 429. 




MB : (\ 



Incision for excision of wrist-joint. 



first row of the carpus is made to present in the wound, and 
the scaphoid is separated from the trapezium and removed ; 
the semilunar and cuneiform should next be removed ; the 
trapezium and pisiform should be left if possible. In re- 
moving the second row of carpal bones the knife should 
be passed between the trapezium and trapezoid and then 
into the carpo-metacarpal joint, and cutting the ligaments 
of the dorsal side of the ends of the metacarpal bones the 
trapezoid, os magnum, and unciform can then be removed. 
The lateral ligaments are next carefully divided, and 



524 



EXCISIONS OR RESECTIONS 



the articular ends of the radius and ulna removed with a 
saw, the euds of the metacarpal bones should next be re- 
moved with a saw or cutting pliers. 

Resection of the Metacarpal Bones. 

The metacarpal bones may be resected by making a 
longitudinal incision on the back of the hand over the 
bone to be removed. The incision should extend from 
one articular end to the other, and the extensor tendon 
when exposed should be held to one side by retractors ; 
the periosteum should next be separated as far as possible, 

Fig 430. 




Resection of metacarpal bone. 

and when the bone has been fully exposed it may be re- 
moved by dividing it in the middle with bone-cutting 
pliers, and then disarticulating each fragment ; or the 
articular ends may be freed and the bone removed in one 
piece. (Fig. 430.) 

ExcrsiON of Metacarpophalangeal Joints or 
Inter-phalangeal Joints. 

In excising a metacarpophalangeal joint the joint is 
exposed by a longitudinal incision over the dorsal surface 



RESECTION OF THE CLAVICLE. 525 

of the knuckle; the extensor tendon being exposed and 
held to one side, the lateral ligaments are divided. The 
articular ends of the bones are tben exposed and removed 
with a metacarpal saw or with bone- cutting pliers. (Fig. 

Fig. 431. 




Excision of the metacarpophalangeal joint. 

431.) In excising the inter-phalangeal joints the incision 
is usually made upon the side of the joint, and when the 
articular surfaces of the bone have been exposed they are 
removed with a small saw or cutting-pliers. 

Resection of the Clavicle. 

The clavicle is resected by making an incision over the 
bone from one articulation to the other, which is carried 
directly down to the bone ; the periosteum is then sepa- 
rated and the shaft of the bone may be divided at the 
middle and each fragment raised and disarticulated, or 
the bone may be disarticulated at one extremity, then 
raised up and freed from its adherent tissues and disar- 
ticulated at the other extremity. In disarticulating the 
sternal articulation of the clavicle (Fig. 432) a probe- 
pointed knife should be used, and great care should be 
exercised to avoid injury of the important vessels and 
nerves which lie in close proximity to it. 

23* 



526 EXCISIONS OB RESECTIONS. 

Fig. 432. 




Resection of the sternal end of the clavicle. 

Resection of the Ribs. 

In excising a rib the incision should correspond in length 
and direction with the portion of bone to be removed, and 
may be crossed at each end by a short transverse incision. 
The tissues overlying the rib are then dissected loose, the 
periosteum is separated as far as possible, and the rib is 
divided by cutting-pliers at two points, and the piece is 
grasped with forceps and the attachments to the under 
surface of the rib are separated with an elevator. Care 
should be taken to avoid opening the pleural cavity. 

Estlander's Operation. 

This operation is employed in cases of empyema, and 
consists in resecting the portions of several adjoining ribs 
to allow the chest wall to sink inward and unite with the 
pleura. The incision is made along the intercostal space 
occupied by the fistula and the adjoining ribs as far as it 
may be necessary. To resect them a flap is then made 
and dissected up, and portions of several ribs are divided 
with bone- cutting pliers and removed with forceps. If 
the costal pleura is very thick, to expose the cavity so as 



EXCISION OF THE SCAPULA. 



527 



to permit of free drainage and allow the chest wall to sink 
in it may be cut away over a part of the area from which 
the ribs have been resected; one to four inches of three to 
six adjoining ribs may be removed. 

Resection of Sternum. 

Resection of the sternum is performed by making a 
longitudinal incision over the portion of the bone to be 
removed ; the periosteum is separated, and the diseased 
portion of the sternum is then carefully freed with an ele- 
vator and removed. 

Excision of the Scapula. 

To excise this bone an incision should be made along 
the whole length of the spine of the scapula, and from its 

Fig. 433. 




Incision for excision of scapula. 



posterior extremity ; two other incisions should be made, 
one running about an inch or two above, and the other 



528 EXCISIONS OB RESECTIONS. 

passing down the posterior border of the bone to its inferior 
angle (Fig. 433) ; the flaps thus made are loosened by sepa- 
rating the muscles attached to the outer surface of the bone. 
The attachments of the deltoid and trapezius to the acro- 
mion and spine of the scapula are separated, the lower 
angle is freed by detaching the teres major and serratus 
magnus. The bone is then raised, and the subscapularis 
muscle is detached from below upward. The neck of the 
scapula should be divided with a chain-saw or cutting 
forceps; the acromion is next separated from the clavicle 
and the scapula turned upward, the joint being opened 
from below. The coracoid process should be separated 
from its muscular and ligamentous attachments, or may 
be divided with a saw and left in place. In clearing the 
supraspinous fossa care should be taken not to injure the 
suprascapular nerve in the suprascapular notch ; it should 
be raised with the periosteum and its fibrous sheath. 

Excision of the Hip. 

In excising the hip-joint an incision is made from a 
point about three inches below the crest of the ilium, and 
about the same distance behind the anterior superior spine of 
the ilium, which should be carried downward over the great 
trochanter in the line of the femur for about five or six 
inches (Fig. 434) ; the soft parts are dissected from the 
great trochanter and upper part of the sheath of the femur, 
and the capsule of the joint is opened. An assistant should 
next rotate the thigh inward and outward, and with a 
blunt-pointed knife the muscles attached to the trochanters 
are shaved off close to the bone; the neck of the femur is 
next freed by the use of a knife and elevator ; the thigh 
is adducted and pushed upward, and the head and neck of 
the bone are made to project from the wound. A transverse 
section of the bone is then made with a saw just below the 
great trochanter. In some cases it is difficult to remove the 
head of the bone, which may be ankylosed firmly to the 
acetabulum ; here the bone may first be divided with a 
chain-saw passed around the femur just below the great 



ANTERIOR EXCISION OF THE HIP. 



529 



trochanter, or may be divided with a chisel, the head and 
neck of the bone afterward being removed with gouge or 
bone-cutting pliers. After the head and neck of the bone 



Fig. 434. 




Incisions for excision of hip-joint. 

have been removed the acetabulum is examined, and if it 
is found to be diseased the diseased tissues should be 
removed with a curette, gouge, and forceps. 



Anterior Excision of the Hip. 

In this method of excising the hip-joint an incision is 
made upon the front of the thigh over the joint, beginning 
half an inch below r the anterior superior spine of the 
ilium, and is carried three or four inches downward and 
a little inward; as the incision is deepened the tensor 
vagina femoris and the glutei muscles are exposed, and 



530 



EXCISIONS OB RESECTIONS. 



should be drawn to the outer side, and the sartorius and 
rectus muscles are held to the inner side, and the neck of 
the femur is exposed ; the neck of the bone is then divided 
with a metacarpal saw or Adams's saw, and the diseased 
portion of the bone is next grasped with strong seques- 
trum forceps, and by the use of these and an elevator the 
head of the bone is removed ; the acetabulum is then ex- 
amined, and, if diseased, the diseased tissue is removed 
with gouge or curette. 

Excision of the Knee-joint. 



Fig. 435. 



The knee-joint is excised by making an incision which 
begins at the inner side of the limb behind the inner con- 
dyle of the femur, and is carried 
over the front of the knee just below 
the patella to a corresponding point 
upon the external condyle of the 
femur (Fig. 435); the flap thus 
formed is dissected up to a point 
corresponding with the upper edge 
of the patella, the ligamentum pa- 
tella is then cut through, the leg is 
slightly flexed, and the joint is 
opened ; the lateral ligaments are 
then divided, and by flexing the leg 
upon the thigh the joint is freely ex- 
posed. The semilunar cartilages are 
next removed, and the condyles of the 
femur are freed ; a narrow-bladed 
saw is placed under the condyles and 
a transverse section of the condyles 
is removed; the head of the tibia is 
next cleared, and a transverse sec- 
tion of this bone is also removed with a saw. The patella 
may be removed before excising the ends of the bone, or, 
if ankylosed to the condyles, may be removed with the 
section of bone which removes a portion of the condyles. 
After sufficient bone has been removed, if localized areas 




Incisions for excision of 
the knee-joint. 



RESECTION OF THE TIBIA OR FIBULA. 531 

of carious bone present themselves upon the sawn surface 
of the bones, they may be removed with a gouge or gouge 
forceps. In excising the knee-joint in young persons care 
should be taken to remove only so much bone as may 
be done without encroaching upon the lines of the epiphy- 
seal cartilages, as removal of the epiphyseal cartilage would 
interfere with the subsequent growth of the bones. 

Arthrectomy of the Knee-joint. 

This operation is employed as a substitute for the oper- 
ation of excision in disease of the knee-joint, and is 
performed by exposing the joint by an incision similar to 
that employed in excision ; the ligamentum patella is 
divided and the patella is reflected with the skin flap. 
When the joint has been freely exposed the diseased artic- 
ular cartilages, semilunar cartilages, crucial ligaments, and 
synovial pouches are removed by the use of the knife or 
scissors and the curette ; if the surface of the bone is found 
to be carious, it is removed by the curette or gouge. After 
the joint has been thoroughly cleared of diseased tissue, it 
is irrigated, and the divided ligamentum patella is sutured 
with several strands of chromicized catgut or silk, and the 
wound is drained and closed. 

Excision of the Patella. 

The patella may be excised by making a longitudinal or 
crucial incision ; the periosteum is carefully separated from 
the bone, and the latter is grasped with strong bone forceps 
and dissected free from its attachments upon the under sur- 
face. The knee-joint is generally opened in removing the 
patella, unless the removal of the bone be undertaken for 
necrosis or caries when it is possible to accomplish its 
complete removal without opening the knee-joint. 

Eesectiox of the Tibia or Fibula. 

In resecting the tibia or fibula the bones may be exposed 
by a longitudinal incision over the bone to be removed, 



532 



EXCISIONS OR RESECTIONS. 



and after the shaft of the bone has been exposed and 
the periosteum separated as completely as possible, the 
shaft of the bone may be divided at its middle and each 



Fig. 436. 




Resection of lower end of fibula. 



fragment grasped with forceps and dissected up, and re- 
moved at its epiphyseal junction. (Fig. 436.) 



Excision of the Ankle-joint. 

In excising the ankle-joint an incision is made at a point 
two inches above the external malleolus, and carried down- 
ward over the fibula to the tip of the external malleolus; it 
is then curved slightly upward toward the dorsum of the 
foot (Fig. 437), care being taken that the incision does not 
extend so far forward as to endanger the extensor tendons 
or the dorsal artery. The bone is exposed in this incision 
and the periosteum is separated and turned aside; the 
peroneal tendons are next exposed and held to one side by 



EXCISION OF THE OS CALCIS. 



533 



Fig. 437. 



retractors ; the external malleolus is next divided with 
bone-cutting pliers and removed, and the astragalus is 
exposed. The upper articulating 
surface of the astragalus is next 
removed with bone forceps or a 
saw, or the whole bone may be re- 
moved. The foot is next inverted 
and the end of the tibia is cleared 
with a probe-pointed knife, care 
being taken not to injure the pos- 
terior tibial artery, nerve, or vein, 
and when the articular surface has 
been freedit is removed with a saw 
or bone-cutting pliers. The articu- 
lar end of the tibia may be exposed 
by making an additional incision 
upon the inner side of the ankle 
over the internal malleolus if de- 
sired. 

Excision of the Astragalus. 




Incision for excision of 
ankle-joint. 



In excising the astragalus a semi- 
lunar incision is made upon the 
outside of the ankle-joint, very 
similar to that employed in excising the ankle ; the exter- 
nal lateral ligaments are divided with a probe-pointed 
knife, and the astragalus is exposed by forcibly inverting 
the foot ; the bone is then seized with strong forceps, and 
its ligamentous attachments are divided with a probe- 
pointed knife, and it is removed. 



Excision of the Os Calcis. 



An incision is made on the level of the upper part of the 
bone, beginning at the inner border of the tendo Achilles, 
dividing this tendon and passing around the back and outer 
surface of the foot to the base of the fifth metatarsal bone; 
a short incision is then made at the anterior end of the first 



534 EXCISIONS OB RESECTIONS. 

incision and carried down to the sole of the foot, the bone 
is exposed and held by forceps ; the flap thus formed, 
which includes the peronei tendons, is then separated from 
the bone, and the cuboid ligaments are cut and also the 
interosseous ligament between the os calcis and the astrag- 
alus, and the bone is removed with forceps. 

Resection of Metataesal Bones. 

Any of the metatarsal bones may be resected by an 
incision on the dorsum of the foot over the bone to be re- 
moved ; the bone is exposed, the extensor tendons being 
held aside by retractors ; the bone is disarticulated at 

Fig. 438. 




Incision for the resection of the metatarsal bone of the great toe. 

either end or is cut in its middle and each fragment dis- 
sected up and removed at its articulation. The metatarsal 
bone of the great toe is exposed by making a curved incision 
over that bone on the inner side of the foot. (Fig. 438.) 

Excision of the Coccyx. 

In excising the coccyx the finger is passed into the 
rectum and the position of the bone is determined; a 
longitudinal incision through the skin and fibrous tissues 
covering the coccyx is made from a point about a quarter 
of an inch above its upper limit, and is carried down to a 
little below its lower extremity. This incision may be sup- 
plemented with a transverse incision. The sacro coccygeal 
articulation is then opened ; an elevator is next introduced 
into the articulation and the bone is raised up and grasped 
with forceps. It should then be freed from its lateral 



EXCISION OF THE SUPERIOR MAXILLA. 



535 



attachments and those upon its anterior surface with a 
knife and elevator. 



Excision of the Superior Maxilla. 

In excising the superior maxilla the incision is begun 
half an inch below the inner canthus of the eye, and is 
carried downward along the line of junction of the nose 
and face and along the course which limits the alse nasi, 
and longitudinally to the septum, and then down through 
the free border of the lip ; it is also advisable to carry the 

Fig. 439. 




Incision for excision of upper superior maxilla. 

incision along the lower edge of the orbit upward over the 
malar bone (Fig. 439) ; the flap being dissected away from 
the surface of the bone, a small, narrow metacarpal saw is 
then applied to the floor of the nostril until a deep groove 
is made ; the soft and hard palate is next divided from 
within the mouth with a strong knife; one or two incisor 
teeth should be removed, and one blade of a pair of strong 
bone-cutting pliers is introduced into the floor of the nose 
in the line of the saw incision, the other is introduced into 
the mouth in the line of the division of the structures of 
the palate, and the bone is divided. The malar bone is 



536 



EXCISIONS OR RESECTIONS. 



next divided with a saw or forceps, and, finally, the blades 
of a strong pair of bone-cutting forceps are introduced, one 
into the nostril and the other at the edge of the orbit, the 
important structures of the orbit being held upward with 
a retractor, and the inner angle of the orbit is cut across ; 
the superior maxillary bone is then grasped with strong, 
lion-jawed forceps, and can be twisted out, any band of 
tissues which holds it being divided with the knife or 
scissors. 

Excision of the Inferior Maxilla. 

Partial or complete excision of the lower jaw may be 
practised. 

Excision of the Ramus and Half of the Body 
of the Lower Jaw. 

The incision should be made from a point just below the 
free border of the lip over the symphysis, and carried 

Fig. 440. 




Incision for excision of the lower jaw. 



down to the lower border of the jaw, from this point it is 
carried along the ramus to the lobe of the ear (Fig. 440); 



EXCISION OF THE LOWER JAW. 537 

the flap is then dissected up, separating the masseter muscle 
from the bone as far as possible without opening the cavity 
of the mouth ; an incisor tooth is next drawn, and the bone 
is sawn through near the symphysis ; the jaw is then 
seized with forceps and drawn downward and forward, and 
denuded upon its inner surface. The insertion of the 
temporal muscle into the coronoid process is divided, and 
the condyle of the jaw is disarticulated from the glenoid 
cavity, and the remaining soft parts are carefully detached 
with a knife or elevator. The facial artery and the inferior 
dental nerve and artery are necessarily divided in removing 
this portion of the jaw. 

Partial Excision of the Lower Jaw or Alveolus. 

The removal of a portion of the alveolar process of the 
jaw may often be accomplished through the mouth without 
the aid of a cutaneous incision. The condyle of the jaw 
may be excised by making an incision close in front of the 
temporal artery and carrying it forward along the zygoma 
for an inch and a half; the tissues being divided and the 
bone exposed, a second incision involving only the skin 
is then carried from the center of the first directly down- 
ward for about an inch ; the soft parts are next carefully 
separated with a knife and elevator from the margin of 
the zygoma and outer surface of the joint, and drawn 
downward with a retractor, to prevent injury of the parotid 
gland, nerves, and vessels. The neck of the condyle is 
then cleared by working around it in front and behind 
with a director, keeping close to the bone to avoid injury 
of the internal maxillary artery. A chain-saw is then 
passed around the neck of the bone, which is divided, and 
the condyle is seized with forceps and removed with an 
elevator or gouge. 



538 TREPHINING. 

Trephining the Skull. 

This is an operation in which a circular disk of bone 
of the skull is removed by a circular saw or trephine to 
expose the membranes and the brain. If a wound is 
already present in the scalp, exposing the skull, as in the 
case of compound fracture of the skull, it is exposed and 
bared, so that the crown of the trephine can be placed 
fairly on the bone ; if no wound exists a U-shaped flap is 
made, including all the structures down to the bone. The 
base of the flap should be so situated as to contain a sufficient 
blood-supply, and the flap should be so planned as to favor 
drainage from the wound. When the bone has been exposed 

Fig. 441. 




Trephine. 

the trephine is placed with the centre pin projecting about 
one-sixteenth of an inch, and the instrument is turned from 
right to left until a groove is made in the bone ; the tre- 
phine is then removed, and the centre pin is raised so that 
as the teeth of the trephine approach the inner table of the 
skull the point of the centre pin will not injure the mem- 
branes or brain. The instrument is then reapplied and 
worked cautiously as the groove in the bone is deepened. 
When the diploe is reached there is usually some bleeding 
from the wound, and as the trephine approaches the inner 
table of the skull it should be manipulated with great care, 
and when the resistance is felt to diminish at any one part 
of the bone the trephine is made to cut at other points of 



TREPHINING THE SKULL. 



539 



the bone where the resistance is still apparent. When the 
disk is completely cut through it can be lifted out in the 
crown of the trephine, or can be removed with forceps or 
an elevator. If the wound has to be enlarged to obtain 
greater exposure of the membranes or brain, it can be done 
very satisfactorily with a form of rongeur forceps. 

Fig. 442. 




1. Trephine opening for mastoid antrum. 2. For abscess from otitis media. 3. 
To expose cerebellum. 4-5. For middle meningeal hemorrhage. A. Lateral 
sinus. B. and C. Limit of up and down variation. (Stimson.) 



When the trephine is applied to expose hemorrhage from 
the middle meningeal artery, or hemorrhage from the 
lateral sinus, or abscess from middle-ear disease, or to open 
the mastoid antrum, the positions for the application of 
the trephine are indicated in Fig. 442. 



540 OPERATIONS UPON NERVES. 

Trephining the Antrum of Highmore. 

The antrum may be opened by extracting the first or 
second molar tooth and deepening its socket with a small 
gouge or bone drill. 

The antrum may also be opened through the mouth to 
avoid a scar upon the face, by the use of a small trephine 
or bone gouge; the gingivo-labial fold is divided up to a 
point just below the infra-orbital foramen, the trephine is 
placed here and a disk of bone removed, opening the antrum. 

Frontal Sinus. 

This sinus may be opened by a trephine or bone gouge. 
An incision is made from the centre of the supra-orbital 
ridge to the median line above the root of the nose. The 
tissues are divided down to the periosteum ; this is incised 
and turned aside, and the trephine or gouge is placed at the 
centre of the incision near the inner edge of the supra- 
orbital ridge and a disk of bone is removed, exposing the 
frontal sinus. 

Operations upon Nerves. 

Neurotomy. 

Neurotomy is an operation in which the nerve trunk is 
exposed and a section made through the nerve. As in the 
case of ligation of vessels, it is most important that the 
operator should have an accurate knowledge of the ana- 
tomical relations of the nerves and the surrounding struc- 
tures. The nerve is exposed by an incision similar to that 
for the exposure of an artery for the application of a 
ligature. 

Neurectasy. 

In the operation of neurectasy, or stretching of nerves, 
the nerve is exposed and isolated and is lifted upon a blunt 



NERVE-GRAFTING. 541 

hook, or, in the case of the larger nerves, is hooked out of 
the wound by the finger, and is thoroughly stretched and 
replaced. 

Neurectomy. 

In this operation the nerve is exposed and a portion of 
the nerve is excised. 



Suture of Nerves or Neurorrhaphy. 

In bringing into apposition the ends of divided nerves 
primary or secondary sutures may be employed. The 
material employed for sutures should be fine silk or fine 
chromicized catgut. 

In using primary sutures the suture in the case of the 
smaller nerves should be passed through the sheath and 
substance of the nerve, and in the larger nerves two sets 
of sutures can be used, one passing through the substance 
of the nerve, the other being passed through the sheath. 

Nerve-grafting. 

In employing secondary sutures to unite the divided ends 
of nerves when there has been a loss of substance in the 
nerve, or there has been so much retraction of the nerve 
that it is impossible to bring the ends together, nerve- 

Fig. 443. 




Nerve-grafting. (Willakd. 



grafting may be made use of; the ends of the nerve being 
freshened, a section of a fresh nerve from an amputated 
limb or animal is sutured to the ends of the divided nerve 
to fill up the gap, as seen in Fig. 443. 

Another method of lengthening the ends of the divided 
nerve, known as neuroplasty, may be employed where the 

24 



542 



OPERATIONS ON NERVES. 



ends cannot be brought into apposition by the ordinary 
method ; in this method flaps are made for the nerve in 



Fig. 444. 



Neuroplasty. (Willard.) 



the same way as in the lengthening of shortened tendons, 
and the ends of the flaps are sutured together, as seen in 
Fig. 444. 

The following incisions are given to expose the nerves 
for some of these various operations : 

Supra-orbital Nerve. 

This nerve is exposed at the supra-orbital notch at the 
junction of the middle and inner thirds of the supra-orbital 




A and B. Incision for resection of supra-orbital nerve. C. Incision for resection 
of the superior maxillary nerve. 



arch. An incision is made one and a half inches in length, 
parallel to the eyebrow (Fig. 445), and is carried down to 



LINGUAL NERVE. 543 

the bone ; the nerve is recognized and grasped with for- 
ceps, and resected or stretched as may be desired. 

Superior Maxillary Nerve. 

A vertical incision is made along the inner side of the 
nose from the bony ridge of the nasal process of the supe- 
rior maxillary bone to the ala of the nose; a second 
incision is begun at the upper part of this incision and 
carried outward along the lower margin of the orbit be- 
yond its centre ; the lower flap is dissected up, and the 
nerve is exposed. The upper flap is next lifted up with 
the lower eyelid and eyeball, exposing the floor of the 
orbit, and the infra-orbital canal can be recognized run- 
ning backward and inward ; the canal is opened with a 
knife or chisel, and the nerve is separated from the artery 
and cut off as far back as may be necessary. The nerve 
may also be reached by exposing the anterior wall of the 
antrum, and trephining this and the posterior wall, and, 
when found, may be cut off close to the exit of the main 
trunk from the round foramen in the sphenoid bone. 

Inferior Dental Nerve. 

To expose this nerve an incision is made along the lower 
jaw, from a point just behind the angle, and carried for- 
ward to a point just in front of the edge of the masseter 
muscle; the periosteum and masseter muscle are then 
separated from the bone with an elevator, and the inferior 
dental canal may be opened with a small trephine or 
chisel ; the exposed nerve is then raised upon a hook and 
resected. 

Lingual Xerve. 

The lingual nerve can be felt just behind the attach- 
ment of the pterygo-maxillary ligament on the inner side 
of the lower jaw, close to the bone, below the last molar 
tooth ; the tongue should be drawn to one side and the 
mucous membrane divided for an inch, parallel to the 



544 



OPERATIONS ON NERVES. 



alveolar process, beginning at the last molar tooth ; the 
nerve is then found in the submucous tissue. 

Facial Nerve. 

This nerve may be exposed at the posterior border of 
the ramus of the jaw by an incision extending from just 
in front of the tragus of the ear to the angle of the jaw. 
The parotid fascia is divided and the cervico-facial branch 
may be exposed first, and can be followed back to its 
junction with the temporo-facial branch. 



Brachial Plexus. 

The brachial plexus consists of the four lower cervical 
nerves and the greater part of the first dorsal ; it lies be- 

FlG. 446. 




Resection of brachial plexus. 



tween the anterior and middle scaleni muscles and crosses 
the floor of the subclavian triangle at the base of the neck. 
To expose the brachial plexus the neck and head are ex- 



THE ULNA AND RADIAL NERVES. 545 

tended and the face is turned toward the opposite side ; an 
incision is made half an inch above the clavicle, between 
the sterno-cleido-roastoid and trapezius muscles, and is 
carried forward for about three inches parallel to the an- 
terior border of the trapezius. The skin and platysma are 
divided, and the external jugular vein is either cut and 
ligatured or held to one side ; the deep cervical fascia is 
next opened in the line of the external incision, and the 
outer border of the anterior scalenes muscle is felt for; 
the brachial plexus is found just outside the latter, and is 
exposed by careful dissection. (Fig. 446.) 

Spinal Accessory Nerve. 

To expose the spinal accessory nerve an incision about 
three inches in length is made downward from the tip of 
the mastoid process along the anterior border of the sterno- 
mastoid muscle ; the cervical fascia should be divided and 
the muscles strongly retracted to put the nerve on the 
stretch. The nerve should be found external to the jugu- 
lar vein, about an inch and a half below the tip of the 
mastoid process on the fascia covering the rectus capitis 
anticus major. 

The Median Nerve. 

The median nerve may be exposed at the bend of the 
elbow or just above the wrist. To expose the median 
nerve at the bend of the elbow an incision is made about 
an inch and a half in length upon the inner edge of the 
biceps tendon ; the bicipital fascia is divided and the 
nerve is exposed at the inner side of the brachial artery. 
The median nerve may also be exposed above the w r rist by 
an incision two inches in length along the inner border of 
the tendon of the palmaris longus muscle. 

The Ulnar and Radial Nerves. 

These nerves may be exposed by an incision similar to 
that employed for ligation of the ulnar or radial artery. 



546 OPERATIONS ON NERVES. 

MUSCULO-SPIRAL NERVE. 

The musculo-spiral nerve is exposed by an incision in 
the outer side of the arm above the elbow, from the upper 
part of the supinator groove ; the fascia being divided, 
the nerve is sought for at the bottom of this groove. 

The Great Sciatic Nerve. 

To expose the great sciatic nerve an incision three or 
four inches in length is made vertically downward from 
the gluteal fold at a point midway between the tuberosity 
of the ischium and the great trochanter; the skin and fascia 
being divided, the lower border of the gluteus maximus 
and the hamstring muscles are exposed ; the nerve rests 
on the external rotators of the thigh just in front of the 
outer side of the hamstring muscles. 

Internal Popliteal Nerve. 

This nerve is exposed by an incision two inches in 
length in the middle of the popliteal space. The nerve is 
slightly external to the vein and artery, and is more super- 
ficially placed. 

External Popliteal Nerve. 

This nerve is exposed by an incision two inches in 
length, parallel and close to the inner side of the biceps 
tendon, and lies close behind and to the inner side of the 
biceps. 

Anterior Crural Nerve. 

This nerve is exposed by an incision about two inches 
in length, extending from Poupart's ligament downward, 
and about an inch to the outer side of the femoral artery. 



TENOTOMY OF SPECIAL TENDONS. 547 

Operations upon Tendons. 
Tenotomy. 

This is an operation which consists in the division of a 
tendon, and it may be done subcutaneously or by an open 
operation. The former method of tenotomy is to be pre- 
ferred in most cases, but in certain tendons which lie in 
close proximity to important vessels and nerves it is 

Fig. 447. 



Sharp-pointed tenotome. 

safer to employ the open operation. In dividing ten- 
dons the parts should be placed in such a position as to 
put the tendon upon the stretch. The instruments re- 
quired are a sharp and blunt-pointed tenotome. (Fig. 
447.) The sharp-pointed tenotome is used to make a 
puncture down to the edge of the tendon, beiug entered 
flatwise ; it is then withdrawn and a blunt-pointed teno- 
tome (Fig. 448) is introduced through the puncture, passed 

Fig. 448. 




Blunt-pointed tenotome. 

under the tendon, and turned so that the tendon rests 
upon its cutting edge ; by a gentle rocking motion the 
tendon is then divided, and the tenotome should be with- 
drawn. 

Tenotomy of Special Tendons. 

Tendo Achillis. 

The tenotome should be entered at the inner border of 
the tendon about an inch above its attachment to the cal- 



548 



TENOTOMY. 



caneum (Fig 449) ; the heel should be depressed as much as 
possible so as to make the tendon prominent, and the knife 



Fig. 449. 




Tenotomy of tendo A chillis. 

should be entered. The posterior tibial artery, nerve, and 
vein lie to the inner side, and are not likely to be injured 
if the tendon is divided from this point. 

Posterior Tibial Tendon. 

This tendon may be divided above the malleolus. The 
muscle is made tense by inverting the foot, and the teno- 
tome is entered at the inner side of the tendon and passed 
behind it. The posterior tibial tendon may also be divided 
upon the side of the foot ; for this operation the foot is 
inverted and the tenotome is passed from above down- 
ward and passed under the upper border of the tendon at 
a point half an inch below and in front of the tip of the 
internal malleolus. 

Anterior Tibial Tendon. 

This tendon is divided upon the dorsal surface of the 
foot just below the annular ligament of the ankle midway 
between the two malleoli. 



Peroneal Tendons. 

The peroneal tendons may be divided about an inch 
above the external malleolus, the tenotome being passed 



EXTENSOR PBOPEIUS POLLICIS. 549 

from before backward between the fibula and the tendons, 
or the tendons may be divided at a point midway between 
the end of the malleolus and the tubercle of the cuboid. 

Hamstring Tendons. 

The inner hamstring consists of the tendons of the semi- 
tendinous, semi-membranosis, gracilis and sartorius. The 
external hamstring consists of the tendon of the biceps. 
To divide either of these tendons the knife is entered at 
the inner side of the tendon. In dividing the external 
hamstring care should be taken to keep close to the tendon 
of the biceps, as the external popliteal nerve lies close to 
its inner border. 

Adductor Longus. 

To divide this tendon abduct the thigh and make the 
muscle prominent near its insertion ; then pass the teno- 
tome from without downward and inward. 

Flexor Longus Pollicis. 

This tendon may be divided on the first phalanx or near 
the inner edge of the foot, where it may be made promi- 
nent by strong extension of the great toe, the tenotome 
being passed close to the border of the tendon. 

Extensor Longus Digitorum. 

These tendons are divided upon the dorsal surface of 
the metatarsal bones, where they are quite prominent. 
They may also be divided near the ankle. 

Extensor Proprius Pollicis. 

This tendon may be divided in the same incision used 
for division of the long flexor of the toes, the point of the 
knife being carried inward. 

24* 



550 OPERATIONS ON TENDONS. 

Sterno-cleido-mastoid. 

In tenotomy of this muscle the sternal and clavicular 
attachments are divided about an inch above the sternum 
and clavicle. A puncture is made to the outer side of the 
muscle with a sharp tenotome, and when the tendinous ex- 
pansion of the muscle is reached it is withdrawn, and a 

Fig. 450. 




Tenotomy of sterno-mastoid. 

blunt tenotome is substituted for it and the structure is 
divided. The sternal attachment is divided through a 
separate puncture in the same way. The external jugular 
vein is to be avoided at the outer border of the muscle. 

Suture of Tendons. 

In bringing together the divided ends of tendons pri- 
mary or secondary sutures are employed ; primary sutures 
are those introduced immediately after the injury, and 
secondary sutures are those introduced after retraction of 
the ends has occurred and the wound has healed. 



SUTURE OF TENDONS, 



551 



Primary Suture of Tendons. 

The material employed for sutures may be silk, silk- 
worm-gut, catgut, or kangaroo-tendon, and one or more 
sutures may be employed, being passed through the sub- 
stance of the ends of the tendon and secured by tying ; the 
divided sheath of the tendon, if possible, should be 
brought together by fine silk sutures. (Fig. 451.) Very 

Fig. 451. 




Sutures passed through the substance of the ends of divided tendon. 

marked retraction of the ends of the tendon is apt to occur, 
and a considerable dissection is often required to bring them 
into view. 

Fig. 452. 




Tendon-suture which does not easily tear out. (Stimson.) 



When there is difficulty in bringing the ends of the 
tendon together, and the sutures are apt to cut out, the 
form of suture shown in Fig. 452 may be employed. 

Secondary Sutures of Tendon. 

In applying secondary sutures to tendons the principal 
difficulty is often encountered in bringing the ends of the 



552 



OPERATIONS ON TENDONS. 



tendon in contact, and in holding them successfully in this 
position. The ends of the tendon have first to be freshened, 
and this may be done by cutting them obliquely, and 
introducing a suture as shown in Fig. 453. This method 



Fig. 453. 




Oblique section of ends of tendon to increase surface of contact. (Stimson.) 

of section presents a larger raw surface of the tendon for 
union. When so large a gap exists between the ends of 
the tendon that they cannot be brought into apposition, a 
plastic operation may be performed upon their ends, which 



Fig. 454. 




Lengthening of retracted tendon by flaps. (Stimson.) 

often overcomes the difficulty. This consists in making 
a section half way through the tendons at some distance 
from their ends, and splitting them toward their divided 
extremities, and then turning out these flaps and securing 
their ends by means of sutures. (Fig. 454.) 



TRACHEOTOMY. 553 



Tracheotomy. 



This operation consists in dividing the tissues over the 
trachea in the median line of the neck, and after the trachea 
has been exposed it is opened by dividing two or three of 
the tracheal rings. 

The operation of tracheotomy may be required to relieve 
the dyspnoea dependent upon membranous or diphtheritic 
laryngitis, growths in the larynx or trachea, growths ex- 
ternal to these organs causing pressure upon them, oedema 
of the mucous membrane of the larynx or trachea from 
inflammation from burns or scalds, or from the inhalation 
of irritating gases or the swallowing of corrosive liquids. 
The operation may also be required for the removal of 
foreign bodies from the larynx, trachea, or from the 
bronchi, as well as for the relief of the dyspnoea due to 
their presence, and it is also required in cases of fracture 
or laceration of the larynx or trachea, and occasionally in 
cases of spasm of the glottis, and in cases of glossitis, to 
overcome the mechanical obstruction which prevents the 
entrance of air into the air-passages. 

The ease with which the operation is performed varies 
much in different cases ; it is, as a rule, a much simpler 
operation in adults than in children. In the latter sub- 
jects the shortness of the neck, the relatively greater size 
of the thyroid gland, and the possible presence of the 
thymus body, the great vascularity of the parts, and the 
abundance of adipose tissue, render the trachea difficult to 
expose and open. 

Under certain circumstances the operation may be per- 
formed with very few instruments ; but if the surgeon has 
the choice he will find it convenient to have at hand two 
small scalpels, one short grooved director, a tenaculum, 
two aneurism needles which may be used as retractors, one 
pair of artery forceps, haemostatic forceps, two pairs of dis- 
secting forceps, a pair of scissors, a sharp-pointed tenotome, 
a pair of tracheal forceps, a tracheal dilator, tracheotomy 
tubes, tapes, ligatures, sponges, a flexible catheter, and 
feathers. The director should be short ; the ordinary 



554 TRACHEOTOMY. 

grooved director is too long to use with satisfaction in 
operating upon the short necks of children ; so that I 
have had made a shorter and somewhat broader one, which 
has a bevelled extremity, which allows it to be passed with 
ease between the different layers of the tissue. (Fig. 455.) 

Fig. 455. 




Author's tracheotomy director. 



Hcemostatie forceps are also of great use in controlling 
hemorrhage during the operation in case of the division 
of vessels which bleed freely, when the operator from the 
urgency of the case does not think it justifiable to ligature 
them at the time of their division. They may also be 
employed und^r similar circumstances to clamp the isthmus 
of the thyroid gland on either side of the trachea when it 
becomes necessary to divide it to expose the trachea. 

A sharp-pointed tenotome is the instrument I prefer to 
employ in opening the trachea, as its sharp point enables 
it to be easily thrust into the trachea, and its short cutting 
surface and the narrowness of the blade obscure as little 
as possible the line of incision, and thus enable the opera- 
tor to see exactly where he is cutting. 

Tracheal dilators of various kinds are employed, but 
the most satisfactory tracheal dilator which I have employed 
is that of Golding-Bird (Fig. 456), which is a self-retain- 
ing instrument ; the blades are slipped through the tracheal 
incision and are then expanded by turning the screw to 
which they are attached. 

Trousseau's tracheal dilator, the blades of which are 
introduced through the incision in the trachea and are 
expanded by bringing together the handles, is also a satis- 
factory instrument (Fig. 457), but is not so useful as the 
tracheal dilator previously mentioned, as it has to be 
retained in position by the hand. Tracheal dilators may 



TRACHEOTOMY. 



555 



be improvised from bent hairpins or pieces of wire, which 
will often serve a useful purpose where ordinary dilators 
cannot be obtained. 



Fig. 456. 



Fig. 457. 





Golding-Bird's tracheal dilator. 



Trousseau's tracheal dilator. 



It is also well to have at hand a number of pliable 
feathers to be used in cleaning the trachea or larynx of 
mucus or membrane after it has been opened, and by their 
use this object can be accomplished with little risk of 
injury to the mucous membrane. 

Tracheal forceps, which are constructed with a double 
spring and curved blades are also useful in removing mem- 
brane or foreign bodies from the larynx above the wound 
or from the trachea below the tracheal incision. (Fig. 458.) 

Fig. 458. 




Tracheal forceps. 

Tracheotomy-tubes of various shapes are made of silver, 
aluminum, hard and soft rubber, but the tube which I 
think is the most satisfactory for general use is a silver 
quarter-circle tube with a movable collar (Fig. 459), and 
provided with a fenestrated guide. (Fig. 460). A good 
tracheotomy-tube is one which inflicts the least possible 



556 



TRACHEOTOMY. 



injury upon the mucous membrane of the trachea, and to 
insure this object the part of the tube within the trachea 



Fig. 459. 



Fig. 460. 





Silver tracheotomy-tube. 



Silver tracheotomy-tube with 
fenestrated guide. 



should lie exactly in its axis, and its free extremity should 
be capable of as little movement as possible. The trache- 
otomy-tube is held in position after being introduced by 
means of tapes attached to the shield of the tube and tied 
around the neck. 



Position of Patient for Tracheotomy. 

The best position in which to place the patient for this 
operation is that which brings the neck into the greatest 
prominence, and this can best be obtained by laying the 
patient upon his back upon a firm table and placing under 
the shoulders a round cushion ; or an empty wine-bottle, 
or a roller-pin wrapped in towels will answer the same 
purpose. If an anaesthetic is not used, the arms should 
be held by an assistant, which is better than securing them 
by a binder fastened around the chest, which restricts 
respiratory movements. 



OPERATION OF TRACHEOTOMY. 557 

Use of an Ancesthetic in Tracheotomy. 

As a rule, I think it is better not to administer an anaes- 
thetic in performing this operation, as little pain is expe- 
rienced, in cases in which the dyspnoea is well marked, 
after the incision in the skin has been made, and I have 
seen the dyspnoea which was well marked before the use 
of the anaesthetic suddenly become so alarming that the 
trachea had to be opened before it was thoroughly exposed, 
which is a procedure always attended with risk. So strong 
is my conviction that the risks of the operation are much 
increased by the employment of an anaesthetic that in later 
years I have abandoned its use. 

Operation of Tracheotomy. 

The trachea may be opened above the isthmus of the 
thyroid gland or below it, and these operations constitute 
respectively the high and low operations. 

The high operation is generally selected, because at this 
point the trachea is more superficial and is more easily 
exposed, whereas in the low operation the trachea is more 
difficult to expose by reason of its relatively greater depth, 
the large size and number of the veins, and its proximity 
to the large arterial trunks. 

The patient being placed in position, and the best posi- 
tion is secured by placing a firm pad under the shoulders 
(Fig. 461), or the head may be dropped over the edge of 
the table, the object being to secure a free exposure of the 
neck and to render the trachea as superficial as possi- 
ble. The operator stands at the head of the patient ; this 
position I prefer, as it is easier from this point to keep the 
incisions exactly in the median line of the neck. The 
operator next makes himself familiar with the landmarks 
of the neck ; locating the position of the cricoid cartilage, 
he makes an incision through the skin in the median line 
of the neck from one and a half to two inches in length, 
the position of the cricoid cartilage being the middle point. 



558 TRACHEOTOMY. 

There is no disadvantage in making a longer incision if a 
freer exposure of the parts is required. Having divided 
the skin, the operator will often see a large vein lying in 
the superficial fascia — the superficial anterior jugular ; 
this should be displaced, and the fascia divided upon the 
director. 

Fig. 461. 





r* 


m&m 


V 




1m' 






-Cisjy 




■:\ : .^y ■■]:::::■ --f. : ! 






HUB 








■';;,. :■':;.;::■■:■,; 


1 WtK^ 


■%: 



Position of patient for tracheotomy. 

The surgeon should keep his incisions strictly in the 
median line of the neck, for this is the line of safety ; and 
he should be careful, as the wound increases in depth, not 
to make the incisions too short, so that it becomes funnel- 
shaped. 

When the deep fascia is exposed it should be picked up 
and divided upon the director, and any large veins in the 
line of the wound should be carefully displaced, or, if 
this is impossible, they should be ligated on each side and 
then divided between the ligatures. 

The operator now looks for the intermuscular space 
between the sterno-hyoid and the sterno-thyroid muscles, 
which can generally be found without difficulty, and the 
muscles are now separated in this line with the handle of 
the knife or with the director, and the isthmus of the thy- 
roid gland will be exposed. The muscles should now be 
held aside by retractors placed on either side. A caution 



OPERATION OF TRACHEOTOMY. 559 

here as to the use of retractors may not be out of place : 
the operator should place them himself and allow the 
assistants to hold them. I once almost lost a case in 
which I had the trachea exposed, and while I turned aside 
to pick up a knife with which to open it, my assistant, in 
replacing a retractor which had slipped, included the 
movable trachea in the grasp of the retractor, pulling it 
to one side and completely shutting off respiration ; when 
I attempted to find the trachea to open it I could only feel 
the anterior surface of the vertebrae at the bottom of the 
wound, and it was only when I appreciated what had 
occurred, and lifted the retractor, allowing the trachea to 
spring back iuto its normal position, that I was able to 
open it. Mr. Durham and Mr. Marsh mention somewhat 
similar cases in which the trachea and vessels were held 
aside with retractors by assistants until the surgeon had 
exposed the cervical vertebrae. 

The operator should carefully explore the wound with 
the finger, to locate exactly the position of the trachea, 
and to ascertain, if possible, the presence of any anomalous 
arteries. 

The isthmus of the thyroid gland having been exposed, 
generally a position over the first three tracheal rings, 
the gland is usually surrounded by a plexus of veins 
which should be displaced with the director, or, if this 
is impossible, they should be ligated on each side and 
divided between the ligatures. The thyroid isthmus is 
next displaced upward or downward, according as the 
surgeon desires to open the trachea below or above this 
body. This is often done without difficulty, especially its 
upward displacement ; but when there is difficulty in dis- 
placing it downward, a procedure recommended by Bose 
may be employed, which consists in making a transverse 
incision across the cricoid cartilage to divide the layer of 
fascia by which the isthmus is bound down ; a director is 
then passed into this incision, and the isthmus is gently 
depressed without difficulty. 

Having displaced the isthmus of the thyroid gland 
upward or downward, the trachea, yellowish-white in 



560 



TRACHEOTOMY. 



appearance, covered by the tracheal fascia, should be ex- 
posed ; this fascia should next be thoroughly broken up 
with the director or handle of the knife so as to bare the 
trachea, and in doing this the operator can feel it crepitate 
under the finger from the suction of air drawn in with 
inspiration. Having arrived at this stage of the opera- 
tion the operator should examine the wound to see that 
it is free from hemorrhage, and he should also replace the 
retractors so as to expose as large a portion as possible of 
the trachea, for, be the case ever so urgent, he now feels 



Fig. 462. 




Opening the trachea. (Liston.) 

assured that he can open the trachea in a moment if the 
breathing should cease. The trachea is now fixed with a 
tenaculum, introduced into it a little to one side of the 
median line ; an incision is made into it with a narrow 
knife from below upward, from one-half to three-fourths 
of an inch in length (Fig. 462), care being taken to see 
that this incision is in the median line, for if the trachea 
be opened by a lateral incision the wound does not heal 
so promptly and the tracheotomy-tube does not fit well, 
and its lower extremity may cause injury to the mucous 
membrane of the trachea. If the wound be a deep one, 



OPERATION OF TRACHEOTOMY. 561 

after fixing the trachea with the tenaculum the operator 
may lift it slightly from its bed, thereby bringing it more 
prominently into view and making it more superficial in 
the wound, thus facilitating its opening. As soon as the 
incision is made into the trachea there is a gush of air 
from the wound in the trachea, mixed with blood or mem- 
brane ; this should be wiped away with a sponge and a 
tracheal dilator should next be introduced and the trachea 
should be cleared of membrane, if it is present in the re- 
gion of the wound, with a feather or with forceps. The 
tracheotomy-tube is next introduced and is secured in 
position by tapes tied around the neck. 

If respiration has ceased, artificial respiration should be 
resorted to or the use of a tube attached to a bellows, or 
Fell's apparatus, and these efforts should be continued for 
at least fifteen minutes, for I have seen resuscitation take 
place in patients who were apparently dead by a persistent 
employment of artificial respiration. 

The care of the tracheotomy-tube is a matter of some 
importance after its introduction ; the inner tube should 
be removed at short intervals, washed and replaced, and 
if the operation has been done for an inflammatory condi- 
tion of the larynx or trachea a moistened feather should 
occasionally be passed through the tube into the trachea 
to withdraw any mncus or membrane which is present. 
In cases of croup after tracheotomy the use of a spray of 
steam or of a spray composed of 

Carbonate of sodium 5j to 5ijss. 

Glycerin fgij. 

Water f'5vi. 

applied by means of a steam atomizer, the spray being 
directed over the opening of the tube, will be found most 
satisfactory in softening the discharges and thus facilitat- 
ing their expulsion through the tube. 

The tracheotomy-tube is usually allowed to remain in 
the trachea from five to ten days ; its permanent removal 
is indicated as soon as the patient is able to breathe through 
the larynx with the wound in the trachea closed ; its use 



562 LARYNGOTOMY. 

may be required for a longer time, but as soon as the in- 
dication for its presence has disappeared the sooner it is 
removed the better, for its presence sometimes sets up a 
troublesome tracheitis. After its removal the wound 
rapidly diminishes in size, the healing taking place by 
granulation and contraction. Difficulty is occasionally 
met with in the permanent removal of tracheotomy-tubes; 
for the causes and treatment of this complication the reader 
is referred to special works upon tracheotomy. 

Where the operation for tracheotomy is done for the 
removal of foreign bodies from the air-passages, the steps 
of the operation are the same, but after the removal of 
the foreign body the treatment of the wound is somewhat 
different. If the foreign body has remained in the trachea 
only for a short time, the wound in the soft parts may be 
closed by means of sutures or may be allowed to remain 
open, being covered by a piece of moistened gauze, and 
the use of the steam spray is here also beneficial for a few 
days. If, however, the body has remained in the larynx, 
trachea, or one of the bronchi for some time, and has set 
up a certain amount of inflammatory trouble, it is better 
to introduce a tracheotomy-tube and allow it to remain 
for a few days. If it is found impossible to locate or re- 
move the foreign body at the time of operation, a trache- 
otomy-tube should be introduced and allowed to remain 
until the foreign body is expelled through the tube or 
removed subsequently by means of forceps. 



Laryngectomy. 

In this operation an opening is made into the air-passages 
through the erico-thyroid membrane. It is a simple opera- 
tion, and one which is practically free from risk, and can 
therefore be performed much more rapidly and safely in 
urgent cases than tracheotomy. 

In this operation the same objection exists to the use of 
an anaesthetic as in tracheotomy, and therefore it should be 
dispensed with. The patient being placed in the recum- 



LARYNGO-TRACHEOTOMY. 563 

bent posture, with the shoulders slightly elevated and the 
head thrown back to make the neck as prominent as pos- 
sible, the surgeon feels for the prominence of the thyroid 
cartilage , and steadying the larynx between the finger and 
thumb of the left hand, he makes an incision in the median 
line over the centre of the thyroid cartilage and extending 
downward for an inch or an inch and a half. The skin 
and superficial fascia being divided, the fascia between the 
sterno-hyoid muscles and the areolar tissue is exposed and 
divided, and the crico-thyroid membrane is exposed. The 
knife is then passed transversely through the membrane 
into the larynx, care being taken that both that membrane 
and the mucous membrane which covers its inner surface 
are divided at the same time. As soon as the knife enters 
the cavity of the larynx blood and mucus will be forcibly 
expelled. 

The wound should be carefully enlarged and a tube 
introduced, which differs from the ordinary traclieotomy- 
tube in being slightly flattened ; this is secured in position 
by tapes tied around the neck as in the case of the ordi- 
nary tracheal tube. The only bleeding which is likely to 
occur is from the crico-thyroid arteries or veins, and if 
these cannot be avoided, and are divided in the operation, 
they should be temporarily secured by haemostatic forceps 
or ligatured, and if the case is not extremely urgent, all 
bleeding should be arrested before the crico-thyroid mem- 
brane is incised. 

The after-treatment of cases of laryngotomy is similar 
to that of cases of tracheotomy ; the same attention is 
required in the care of the tube and in the general man- 
agement of the patient. 



Laryngo-tracheotomy. 

This operation consists in making an incision into the 
air-passages by dividing one or two of the upper rings of 
the trachea, the crico-tracheal membrane, the cricoid 
cartilage, and the crico-thyroid membrane. This opera- 



564 



INTUBATION OF THE LARYNX, 



tion is employed in cases where, from the age of the 
patient, the crico-thyroid space is too small to admit of a 
sufficient opening, or in those in which, for any reason, 
the surgeon does not deem it advisable to attempt to open 
the trachea lower down. The incision in the skin and 
superficial fascia of the neck is made in the same manner 
as in the operation of laryngotomy, but is carried a little 
further downward. It may be necessary to displace the 
isthmus of the thyroid gland downward to expose the 
upper portion of the trachea, and when the trachea is 
exposed the incision should be made through this and the 
cricoid cartilage from below upward. 

This operation is more often performed in the high 
operation of tracheotomy than is generally supposed. A 
tracheotomy tube is introduced through the wound and 
secured by tapes tied around the neck, and the care of the 
tube should be similar to that in cases of tracheotomy. 



Intubation of the Larynx. 

This procedure, at the present time, is widely employed 
as a substitute for tracheotomy in the treatment of the 



Fig. 463. 




Mouth-gag. 



INTUBATION OF THE LARYNX. 



565 



dyspnoea due to inflammatory affections of the larynx or 
trachea, or stenosis of the larynx; it consists in the intro- 
duction of a metallic tube into the larynx, which is allowed 
to remain in place for a few days. The operation has been 
recently reintroduced to the profession by Dr. O'Dwyer, of 
New York, who has devised a set of ingenious instruments 
for the purpose of laryngeal intubation. 



Fig. 464. 




Intubation-tube and introductory 



The instruments required are a mouth-gag (Fig. 463), 
with which the jaws are separated and held open ; an in- 
strument for the introduction of the tube, which is fastened 
to the obturator which fills the cavity of the tube (Fig. 



Fig. 465. 




Intubation-tube extractor. 



464), and an instrument for extracting the tube after it 
has been placed in the larynx. (Fig. 465.) The tubes 
are of metal and have a collar which rests upon the 
false cords and bulge slightly toward their middle and 
again taper toward their lower extremity ; at the collar 
of the tube there is a perforation through which a strand 
of silk is passed which is made into a loop ; this is used 

25 



566 



INTUBATION OF THE LARYNX. 



Fig. 466. 



to allow the operator to remove the tube if on its introduc- 
tion it is found to have passed into the oesophagus irjstead 
of the larynx, and also is used to remove 
the tube if it becomes occluded with mem- 
brane while in the larynx. The intuba- 
tion set now in common use is provided 
with a scale of six tubes ranging in size 
from such as are suited for a child of one 
year or less up to the age of twelve or 
fourteen years. (Fig. 466.) 

In performing the operation of intu- 
bation of the larynx the child is placed 
upon the lap of the nurse or assistant, 
wrapped in a blanket, and the arms are 
secured by the nurse holding the elbows 
so as not to interfere with the respiratory 
movements. 

The patient's head is next secured by 
an assistant, and the position of the head, 
neck, and body should be as if he were 
hung from the top of the head, and this 
position should be firmly maintained dur- 
ing the insertion of the tube. The mouth-gag is next in- 
serted upon the left side and the blades dilated so as to open 
the jaws widely, and as the gag is self-retaining this position 
is easily maintained. The jaws being thus held open, the 
operator, sitting on a chair facing the patient (Fig. 467), next 
introduces the index-finger of the left hand, protected by a 
strip of adhesive plaster, into the mouth and passes it over 
the tongue until he feels the epiglottis ; the introducing- 
instrument to which the tube is attached is held in the right 
hand, and this is now introduced into the mouth, first seeing 
that the silken loop is free, and it is swept over the tongue 
and passed down until it touches the epiglottis; this is 
hooked up by the index-finger of the left hand and the tube 
is passed into the larynx; the index-finger of the left hand 
is then transferred to the edge of the tube, and by drawing 
upon the trigger of the instrument with the index-finger 
of the right hand the obturator is detached and the instru- 



Scale of intubation- 
tubes. 



INTUBATION OF THE LARYNX. 



567 



ment is withdrawn, and before removing the finger it is 
well to place it upon the head of the tube and to sink it 
well into the larynx. As soon as the obturator is removed 
there is usually a violent expiratory effort which is accom- 
panied by a gush of mucus, muco-purulent matter, or mem- 
brane from the tube, and after this escapes the breathing 



Fig. 467. 




*4 



Intubation of the larynx. 

is usually satisfactorily established. If the operator has 
passed the tube into the oesophagus and has detached it 
from the introducing-instrument, no improvement in the 
respiration takes place ; it should then be withdrawn by 
the silk loop and attached to the obturator and another 
attempt should be made to introduce it into the larynx. 

The mistake which inexperienced operators make in 
attempting to introduce the tube is in not hugging the 



568 INTUBATION OF THE LARYNX. 

posterior surface of the tongue closely, so that they pass 
the tube over the epiglottis into the oesophagus. 

The silken loop may be brought out at one side of the 
mouth and fastened around the ear or fastened to the side 
of the face by strips of adhesive plaster for a few hours, 
so that by drawing upon it the nurse or attendant is able 
to withdraw the tube instantly if it should become ob- 
structed with membrane ; or, if it is coughed up, by this 
means it may be withdrawn from the oesophagus if it has 
not been expelled from the mouth. Some operators keep 
the loop attached to the tube during the time it is retained 
in the larynx. I prefer to remove it after the tube is se- 
curely placed in the larynx, and remove the tube by means 
of the extracting-instrument when required. The tube is 
removed at the end of the second or third day, and if the 
child is able to breathe comfortably for an hour or two it 
is not reintroduced ; if, however, the dyspnoea returns it 
is reintroduced and allowed to remain one or two days 
longer ; several attempts may have to be made before the 
tube is permanently removed, but it is usually dispensed 
with from the third to the eighth day. 

The most serious complication which is apt to occur 
during the introduction of the intubation-tube is the de- 
tachment and pushing of a mass of membrane in front of 
the tube into the trachea ; if this is too large to be expelled 
through the tube, the breathing is suddenly arrested. The 
tube should be removed at once, and if the mass of membrane 
does not escape upon the expiratory efforts of the patient 
the trachea should be rapidly opened as the only means 
of re-establishing the respiratory function. So much do 
I dread this accident, which has occurred in a few cases, 
that I never introduce the intubation-tube without having 
at hand the necessary instruments to do a tracheotomy if 
it should be suddenly required, and if possible obtain the 
consent of the parents or friends to perform tracheotomy 
if it should be indicated. 

One of the greatest troubles after intubation of the 
larynx is the satisfactory feeding of the patient ; liquids 
as a rule are not swallowed well, a portion of them escaping 



INTUBATION 01 THE LARYNX. 



569 



into the tube, causing coughing and difficulty in breathing. 
The diet I usually order is of semi-solids, such as corn- 
starch, soft-boiled eggs, and mush ; and if these are not 



FIG. 468. 




Feeding a case of intubation of the larynx. 



well swallowed, it may be necessary to resort to nutritious 
enemata or the use of a stomach-tube to introduce food. 
Some patients swallow liquids and semi-solids quite well 
if the head is dropped a little lower than the body during 
the act of deglutition. (Fig. 468.) 



570 OPERATIONS. 

Operations upon the Kidney. 

Nephrotomy. 

In this operation an incision is made into the kidney. 
The incision for exposure of the kidney is four inches in 
length, and should be made from a point two and a half 
inches from the spine, half an inch below the last rib and 
parallel with it. The latissimus dorsi, external and internal 
oblique, and transversalis muscles are divided, and the 
lumbar fascia is opened, exposing the perinephric fat ; the 
kidney is then reached by displacing this. 

Lumbar Nephrectomy. 

The incision is the same as for nephrectomy, but the 
wound can be enlarged by another incision at right-angles 
to the first, if more space is required. After the kidney 
is exposed its capsule is incised, and the finger is passed 
around the organ to separate it freely from the capsule. 
When the ureter is recognized it is brought into view, liga- 
tured, and cut off. The pedicle containing the vessels is 
next tied, and it is then divided in advance of the ligature 
with scissors, and the kidney is removed. 

Abdominal Nephrectomy. 

To reach the kidney by abdominal incision an incision 
four inches long is made at the outer border of the rectus 
muscle; the abdomen is opened and the viscera turned 
aside ; the kidney is exposed and the capsule is opened ; 
the ureter is ligated and the vessels are tied and the organ 
is removed. 

Nephrorrhaphy. 

Nephrorrhaphy is an operation in which the kidney is 
exposed through the same incision as that for nephrotomy, 
with the object of suturing a movable kidney fast in its 



INGUINAL COLOTOMY, OB COLOSTOMY. 



571 



normal position in the back ; when the kidney has been 
reached a number of sutures are introduced into the cap- 
sule of the kidney, and secured to the fibrous and muscular 
tissue of the incision. 



Operations upon the Colon. 

Lumbar Colotomy, or Colostomy. 

In performing lumbar colotomy on the left side, the 
patient should be placed upon the right side, and a pillow 
should be placed under the loin to make the left side more 
prominent. An incision four inches in length is made 
midway between the last rib and the crest of the ilium, 
the centre of the incision corresponding to the point mid- 
way between the anterior superior and posterior superior 
processes of the ileum ; the tissues are divided to the full 

Fig. 469. 




Incision in lumbar colotomy — dotted line shows situation of the colon. 



extent of the wound, until the lumbar fascia and edge of 
the quadratus lumborum muscle have been reached ; the 
former being cut through and the fascia divided, the bowel 
is exposed, when it is brought to the surface and fastened 
by sutures and opened. 



572 OPERATIONS. 

Inguinal Colotomy, or Colostomy. 

In the operation of inguinal colotomy an incision two 
or three inches in length is made on the left side parallel 
to and one inch above Poupart ? s ligament, with its centre 
on the level of the anterior superior spine of the ileum, or 
a little lower, or as practised by Ball, the colon may be ex- 
posed by an incision two and a half inches in length, fol- 
lowing the line of the linea semilunaris, stopping just short 
of Pou part's ligament, the tissues are divided layer by layer, 
and the peritoneum is opened ; the skin and parietal peri- 
toneum may be united by a few sutures, and the gut is 
then brought out at the wound and fastened to its margins 
by fine sutures and is next opened. 

Kemoval of the Appendix Vermiformis. 

To expose the appendix an incision three to four inches 
in length at the outer border of the right rectus muscle is 
made, with its centre on a line drawn between the umbilicus 
and the anterior superior spine of the ileum ; the tissues 
are divided layer by layer and the peritoneum is picked 
up and opened ; the anterior longitudinal band is recog- 
nized and traced down to its origin at the appendix. 
When the appendix is found the meso-appendix is liga- 
tured and the appendix is removed. In removing the 
appendix a circular incision may be made around it near 
its base, and the cuff* may be turned back ; the body of 
the appendix is then ligated, and the turned-back cuff is 
then brought forward and united by fine silk or catgut 
sutures. 

Left Lateral Lithotomy. 

In performing this operation the patient is placed upon 
his back, the hands and feet are secured together, the 
bladder is injected with a few ounces of boric solution ; 
a grooved staff is introduced into the bladder, and the 
operator first passes one finger into the rectum to locate 



SUPRAPUBIC LITHOTOMY. 



573 



the position of the staff as regards the prostate ; an inci- 
sion is then made a little to the left of the raphe of the 
perineum, a quarter to half an inch in front of the anus, 



Fig. 470. 




Deep incision in lateral lithotomy. (Fergusson.) 

and is carried downward by careful strokes of the knife 
until the staff is reached, about half an inch in front of 
the prostate. When the point of the knife enters the 
groove in the staff it is pushed backward, keeping it well 
in the groove until the prostate is incised and a gush of 
fluid escapes along the knife ; the index-finger is then in- 
troduced and the stone-located ; stone forceps are next 
introduced and the stone is removed. (Fig. 470.) 



Suprapubic Lithotomy. 

The operation of opening the bladder above the pubes 
may be performed for the removal of stone from the blad- 
der, or for the extirpation of growths, or for drainage of 
the bladder. The hair on the pubes should be shaved off 
and the bladder should be injected with a few ounces of 
fluid and a rubber band tied around the penis ; a small 

25* 



574 



OPERATIONS. 



rubber bag is then introduced into the rectum empty and 
filled with air or water. An incision two or three inches 
in length is made in the median line of the abdomen just 
above the symphysis pubis, and is deepened gradually 
until the fascia is reached ; this is divided and exposes the 
prevesical fat ; when this is displaced the wall of the blad- 
der is exposed to view. A tenaculum is next introduced 
into the highest part of the vesical wall to fix it, and a 
knife is then thrust through the wall of the bladder and 
the incision is carried downward about an inch. After 
the bladder is opened forceps are introduced and the cal- 
culus is removed. If the bladder-walls are healthy, the 
wound may be sutured with stitches, which do not pass 
through the mucous coat. The external wound is then 
sutured and the bladder is drained by a soft catheter passed 
by the urethra. If the bladder-walls are much diseased, 
the wound is left open, and drainage is effected by a 
rubber tube passed through the suprapubic wound in the 
bladder. 

Circumcision. 

Circumcision is performed by drawing the prepuce for- 
ward and then enclosing it in a pair of clamp-forceps 



Fig. 471. 




Circumcision. 



CHOLECYSTOTOMY. 575 

placed obliquely just in front of the glans. (Fig. 471.) 
The prepuce is next divided with a straight bistoury, the 
forceps are removed, and the skin and mucous membrane 
retract. The mucous membrane, if adherent, is dissected 
loose from the glans, and, if redundant, is trimmed off with 
scissors to make it correspond to the line of skin incision, 
and the cut edge of the mucous membrane is next fastened 
to the cut edge of the skin by a few sutures of silk or cat- 



gut. 



Kemoval of the Testicle. 



In removing the testicle a longitudinal incision is made 
over the upper part of the gland and cord and the en- 
velopes of the testicle and cord are divided ; the cord is 
then exposed and is ligatured, or the different elements of 
the cord may be separated and tied independently ; the 
gland is then removed and the cord divided in advance 
of the ligature. 

Operation for Varicocele. 

In operating for varicocele the dilated veins of the sper- 
matic cord may be ligatured by a subcutaneous ligature 
passed around the cord, care being taken to see that the 
vas deferens is not included. Or the veins of the cord are 
exposed by an incision at the upper part of the scrotum 
over the cord almost an inch and a half in length. The 
veins are exposed and the larger portion of them are iso- 
lated, and two ligatures are passed around the mass of 
veins about an inch or an inch and a half apart and firmly 
tied. The portion of the cord between the ligatures is 
excised and the divided ends of the veins are brought in 
contact by tying together the ends of the ligatures upon 
the proximal and distal ends of the veins ; the wound is 
drained and closed with sutures. 

Cholecystotomy. 

An incision three or four inches in length is made verti- 
cally downward from the lower border of the liver oppo- 



576 OPERATIONS. 

site the tip of the lower border of the tenth rib ; the tissues 
are divided and the peritoneum is opened. The gall- 
bladder is then exposed, opened and sutured to the edges 
of the wound. If the gall-duct is to be explored, this is 
done with the finger from without or by a probe. After 
the gall-bladder has been opened and the stone removed, 
it may be closed by sutures, or it may be left open, its 
edges being sutured to the external wound. 



External GEsophagotomy. 

A sound is passed through the mouth into the oesophagus 
until its point comes in contact with the stricture of the 
oesophagus or the foreign body which requires removal. 
An incision is then made from a point one inch above the 
sternum to the line of the upper border of the thyroid 
cartilage on the inner side of the sterno-cleido mastoid 
muscle ; the anterior jugular vein is displaced, the fascia is 
divided, the omo-hyoid muscle is drawn aside, the sterno- 
mastoid muscle and the vessels are drawn to the outer side 
with blunt hooks, then by dissecting down with the finger 
the oesophagus is exposed ; the sound which has been 
passed into the oesophagus can easily be felt, and the 
oesophagus is incised upon the point of this sound. If a 
permanent opening is desired, the edges of the oesophagus 
are sutured to the skin. 

Gastrostomy. 

An incision one and a half to two inches is made 
parallel to and a finger's breadth from the border of the 
left costal cartilage, ending opposite the border of the tenth 
rib ; the tissues are divided layer by layer until the peri- 
toneum is reached (Fig. 472). The latter membrane 
should be pinched up and opened ; the stomach is recog- 
nized and brought out of the wound ; the parietal perito- 
neum is stitched to the skin around the wound, and a 
fold of the unopened stomach is brought out of the wound 



OSTEOTOMY. 



577 



and transfixed by pins. The opening of the stomach is 
delayed for some days if possible, to allow of the forma- 



Fig. 472. 




Anatomical relations of stomach. (Stimson.) 

tion of adhesions between its surface and the parietal 
peritoneum. 

Osteotomy. 

This operation consists in dividing the bones with a saw 
or osteotome, and is employed to correct deformities of the 
bones. 

Fig. 473. 




>*s^g. 



Adams' saw. 



The instruments employed are a saw with short cutting 
surface, Adams's saw (Fig. 473), or osteotomes (Fig. 474) ; 



Fig. 474. 




ggpSEigBBSa ggg 



Macewen's osteotome. 



3X9 



a heavy mallet is used to drive the osteotome through the 
bone. Osteotomy is employed to correct deformities of the 



578 



OPERATIONS. 



femur following coxalgia, and here the femur is divided 
either at the neck, Adams's operation, or just below the 
trochanters, Gant's operation. 



Osteotomy of the Femur below the Trochanters. 

A puncture is made with a bistoury oil the outer side of 
the femur just below the great trochanter, and is carried 
down to the bone ; the blade of the saw is then introduced 
and the femur is divided by the saw from before backward. 
The femur may also be divided in this position with an 
osteotome. 

Osteotomy for Knock-knee. 

The operation employed to correct this deformity is a 
transverse section of the femur above the condyles. (Fig. 
475.) In the operation of supra-condyloid osteotomy the 

Fig. 475. 




A. Epiphyseal line. C. Line of bone section in supra-condyloid osteotomy. 



knee is flexed and supported on a sand-bag. A longi- 
tudinal incision one inch in length is made half an inch 



OSTEOTOMY. 579 

anterior to the tendon of the abductor magnus and a 
finger's breadth above the internal condyle ; the knife is 
carried down to the bone, and before it is withdrawn an 
osteotome is introduced and its edge turned so as to divide 
the bone transversely. The section of the bone is accom- 
plished by the use of the osteotome and mallet. After the 
bone has been divided the deformity is corrected, the 
wound is closed, and the limb is put up in a plaster-of- 
Paris dressing in the corrected position. 

Osteotomy for Bowlegs. 

To correct this deformity the tibia and fibula are divided 
at the point of greatest bowing with an osteotome. The 
fibula is divided first at the point of greatest bowing by 
an osteotome entered through a puncture over the fibula, 
and next the tibia is divided in the same manner. The 
bones being divided, the deformity is corrected and the 
limb is put up in a plaster-of- Paris dressing in the cor- 
rected position. Osteotomy may also be employed to 
correct deformities in other positions, or for the deformity 
resulting from fractures united in faulty position. 



INDEX. 



4 BDOMINAL aorta, ligation of, 
i\ 444 

nephrectomy, 570 

tourniquet, 510 
Abscess, acute, 304 

chronic, 305 

diffused, 306 

treatment of, 304 

tuberculous, 305 
Absorbent cotton, 160 
A.-C.-E. mixture, 240 
Acid, boric, 130 

carbolic, 126 
Actual cautery, 186 
Acupressure in arterial hemor- 
rhage, 294 

method of, 294 et seq. 
Acupuncture, 183 

needles, 183 
Acute abscess, 304 
Adductor longus tendon, tenotomy 

of, 549 
Adhesive plaster, 164 
Aluminum aceticum, 128 
Ambulant method of treatment in 

fractures of the leg 380 
American bandage of foot, 88 
Amputating knives, 464 

saws, 465 
Amputation or amputations, 459 

at ankle-joint, 497 
Hancock's, 500 
PirogofFs, 498 
Koux's, 500 
Syme's, 497 

of arm, 481 

circular, 460 

details of, 469 

at the elbow, 480 



Amputation, elliptical, 462 
of fingers, 473 
flaps in, 460 
of the foot, 489 

Chorpart's, 495 

Hey's, 495 

Lisfranc's, 494 

Tripier's, 501 
of forearm, 479 
of hand, 473 

carpo-metacarpal, 477 
hemorrhage in, control of, 469 
of hip-joint, 510 

Guthrie's, 512 

Wyeth's,513 
pins in, 513 
instruments for, 464 
at knee-joint, 505 

Carden's, 506 

Gritti's, 507 
of leg, 501 

of metacarpal bones, 476 
of metatarsal bones, 491 
modified circular, 463 
oval, 462 

periosteal flaps in, 464 
redressing of, 471 
retractors for, 467 
above shoulder-joint, 488 
at shoulder-joint, 484 

Dupuytren's, 486 

Larrey's, 485 

Lisfranc's, 487 

Spence's, 487 

Wyeth's pins in, 485 
subastragaloid, 497 
tarso-metatarsal, 493 
Teale's, 463 
of thigh, 507 



582 



INDEX. 



Amputation of toes, 489 
tourniquets in, 469 
at wrist, 478 
Anaesthesia from chloride of ethyl, 
229 
from cocaine, 230 
from cold, 229 
infiltration, 231 
local, 229 

from rapid respiration, 230 
Anaesthetics, 229 

in tracheotomy, 557 
Aneurism needle, 293 
Ankle, dislocations of, 418 
Ankle-joint, amputation at, 497 
Hancock's, 500 
PirogofFs, 498 
Boux's, 500 
Syme's, 497 
excision of, 532 
Anomalous dislocations of femur, 

415 
Anterior crural nerve, excision of, 
546 
tibial artery, ligation of, 453 
tendon, tenotomy of, 548 
Antisepsis, 119 
Antiseptic bandages, 143 

dressing, improvised, 143 
method, 123 
operation, 150 
poultice, 173 
Antrum of High more, trephining 

of, 540 
Aorta, abdominal, ligation of, 444 
Appendix vermiformis, removal of, 

572 
Aquae ammonia as rubefacient, 
180 
as a vesicant, 182 
Aristol, 131 
Arm, amputation of, 481 

and chest bandage, 73 
Arteriotomy, 195 
Arterial transfusion, 199 

hemorrhage, 281 See Hemor- 
rhage 
Arteries, ligation of, 424 

wounded, treatment of, 299 
Arteriversion in arterial hemor- 
rhage, 292 



Artery, anterior tibial, ligation of, 
453 
axillary, ligation of, 436 
brachial, ligation of, 438 
common carotid, ligation of, 
431 
iliac, ligation of, 445 
dorsalis pedis, ligation of, 455 
external carotid, ligation of, 
433 
iliac, ligation of, 447 
facial, ligation of, 435 
femoral, ligation of, 449 
gluteal, ligation of, 448 
inferior thyroid, ligation of, 

430 . 
innominate, ligation of, 427 

internal carotid, ligation of 

433 

iliac, ligation of, 447 

mammary, ligation of, 430 

pudic, ligation of, 449 

interosseous, ligation of, 444 

lingual, ligation of, 434 

occipital, ligation of, 435 

popliteal, ligation of, 452 

posterior tibial, ligation of, 456 

radial, ligation of, 440 

sciatic, ligation of, 449 

subclavian, ligation of, 428 

superior thyroid, ligation of, 

434 

temporal, ligation of, 436 

ulnar, ligation of, 442 

vertebral, ligation of, 430 

Arthrectomy of knee-joint, 531 

Artificial respiration, 201 

direct method of, 203 

Hall's method, 207 

Laborde's method, 207 

Sylvester's method, 205 

Asepsis, 119 

Aseptic dressings, improvised, 143 

method, 123 

operation, 153 

Aspiration, 208 

Aspirator, 209 

Astragalus, dislocation of, 420 

excision of, 533 

fracture of, 385 

Axillary artery, ligation of, 436 



INDEX. 



583 



BACILLUS pyogenes, 121 
fcetidus, 121 
Bandage or bandages, 13 et seq 
antiseptic. 143 
arm and chest, 73 
Barton's, 41 

modified, 43 
of breast, suspensory and com- 
pressor, 78 
circular, 19 
compound 24 
crossed, of both eyes, 53 

of eye, 52 
demi-gauntlet, 60 
Desault's, 69 
dimensions of, 17 
figure-of eight, 23 

of chest, 76 

of elbow, 63 

of knee, 85 

of leg, 91 

of neck and axilla, 67 
of finger, spiral, 57 
flannel, 98 
of foot, American, 88 

French 89 
in fractures, 330 
gauntlet, 58 
Gibson's. 44 
glue and zinc, 116 
gum and chalk, 114 
handkerchief, 29 
hardening, 100 
bust and neck, 51 
Liebreich's. 96 
lithotomy, 95 
many-tailed, 28 
occipitofacial, 54 

-frontal, 56 
oblique, 20 

of head, 55 

of jaw, 41 
paraffin, 115 
plaster-of-Paris, 101 

application of, 102 

preparation of, 102 

removal of, 112 

trapping of, 110 
recurrent, 24 

of head, 47 

of stump, 94 



Bandage, reversing of, 18 
rubber, 98 
scissors, 19 

silicate of potassium, 115 
silicate of sodium, 115 
of Scultetus, 97 
spica, 22 

of foot, 87 

of groin, double, 83 

single, 80, 8L 
of shoulder, ascending, 64 

descending, 66 
of thumb, 61 
spiral, 20 

of chest, 75 
reversed, 21 

of lower extremity, 90 
of penis, 93 
of upper extremity, 62 
starched, 114 
transverse recurrent, of head, 

49 
V-, of head, 50 
varieties of, 19 
Yelpeau's, 68 
Bandaging, 13 

general rules for, 17 
Barton's bandage, 41 
modified, 43 
handkerchief, 40 
Bavarian dressing, 108 
Bedsores, 314 
Beta-naphtol. 128 
Bichloride cotton, 144 
of mercury, 125 
gauze, 140 
Binders' board splints, 117, 328 
Bisaxillary cravat, 34 
Bladder, hemorrhage from, treat- 
ment of, 303 
irrigation of, 253 
Bloodletting, 188 
Blood, transfusion of, 195 
direct, 196 
indirect, 197 
Bone chips, preparation of, 220 
forceps, 466 
grafting, 219 
Bouisson's suture, 269 
Borated gauze, 142 
Boric acid, 130 



584 



INDEX. 



Boro-salicylic lotion, 130 
Bougies, 247 
Bougie, oesophageal, 212 
Bowlegs, osteotomy for, 579 
Brachial artery, ligation of, 438 

plexus, excision of, 544 
Bran bags, 329 
Bread poultice, 172 
Breast, strapping of, 167 
Breasts, bandage of, 80 

suspensory bandage of, 78 
Bromide of ethyl, 241 
Bruises, 311 
Brush-burn, 312 
Buried suture, 260 
Burns, 312 
Butcher's saw, 517 
Buttock, spica bandage of, 84 
Button suture, 264 



pALCANEUM, dislocation of, 
\J 420 

fracture of, 384 
Cantharidal collodion, 181 
Cantharidis, ceratum, 181 
Capillary hemorrhage, treatment 

of, 298 
Capsicum as rubefacient, 180 
Carbolic acid, 126 
Carbolized gauze, 141 
Carbuncle, strapping of, 170 
Carden's amputation at knee-joint, 

506 
Carpal bones, fracture of, 363 
Carpus, dislocation of, 409 

of bones of, 410 
Cartilages, semilunar, dislocation 

of, 418 
Catgut, 134 

sterilization of, 135 
Catheters, 245 

female, introduction of, 251 

flexible, 245 

introduction of, 249 

metallic, 245 

prostatic, 246 

securing of, in bladder, 251 
Cautery, actual, 186 

irons, 186 

Paquelin's, 187 



Cauterization in arterial hemor- 
rhage, 291 
Ceratum cantharidis, 181 
Chain saw, 517 
Charcoal poultice, 172 
Chemical sterilization in wounds, 

146 
Chest, Estlander's operation upon, 
526 

figure-of-eight bandage of, 76 

spiral bandage of, 75 

strapping of, 167 

T-bandage of, 25 
Chin, four-tailed bandage of, 28 
Chloride of ethyl, 229 

of zinc, 1*28 
Chloroform, 238 

administration of, 238 

as rubefacient, 179 

as a vesicant, 182 
Cholecystotomy, 575 
Chopart's amputation of foot, 495 
Chronic abscess, 305 
Circular bandage, 19 

amputation, 460 
Circumcision, 574 
Clavicle, dislocation of, 399 

fracture of, 343 

resection of, 525 
Clinical thermometer, 226 
Closed fracture, 319 
Cocaine, 230 

local anaesthesia from, 230 
Coccyx, dislocation of, 396 

excision of, 534 

fracture of, 340 
Cold, anaesthesia for, 229 

in arterial hemorrhage, 289 

compresses, 177 

water dressings, 177 
Colles' fracture, 361 
Collodion, cantharidal, 181 
Colon, operations on, 571 
Colostomy, inguinal, 572 

lumbar, 571 
Colotomy, inguinal, 572 

lumbar, 571 
Comminuted fracture, 319 
Common carotid artery, ligation of, 
431 

iliac artery, ligation of, 445 



INDEX. 



585 



Complete dislocation, 393 

fracture, 318 
Complicated dislocation, 393, 423 

fracture, 320 
Compound bandages, 24 

dislocation, 393, 423 

fracture, 319 

dressing of, 387 
Compresses, 162 

cold, 177 

hot, 173 

in fractures, 330 
Condyles of femur, fracture of, 374 
Congenital dislocations, 423 
Constriction of arteries in arterial 

hemorrhage, 292 
Continued suture, 261 
Contused wounds, 309 
Contusions, 311 
Coronoid process of ulna, fracture 

of, 358 
Costal cartilages, fracture of, 339 
Cotton, 160 

absorbent, 160 

bichloride, 144 
Counter-irritation, 178 
Creolin, 129 

Crossed bandage of eyes, 52 
Cupping, 189 

dry, 190 

glass, 190 

wet, 191 
Cyanide of mercury and zinc, 131 

gauze. 141 
Cystoscope, 222 
Czerny suture, 270 



DEFOEMITY in fracture, 322 
Demi-gauntlet bandage, 60 
Desault's bandage, 69 
Diffused abscess, 306 
Digital compression in hemor- 
rhage, 281 
Direct method of artificial respira- 
tion, 203 
transfusion of blood, 196 
Disinfection of the hands, 147 
Dislocation or dislocations, 393 
of the ankle, 418 
of astragalus, 420 



Dislocation of bones of carpus, 410 
of calcaneum, 420 
of carpus, 409 
of clavicle, 399 
of coccyx, 396 
complicated, 393, 423 
complete, 393 
compound, 393, 423 
congenital, 423 
of elbow, 405 
of femur, 412 

anomalous, 415 

dorsal,412 

ischiatic, 412 

pubic, 415 

thyroid, 413 
of fibula, 418 
of fingers, 410 
of head of humerus, 401 

of radius, 407 
of hip, 412 

of humerus, Kocher's method 
in, 403 

reduction of, 402 

subclavicular, 402 

subglenoid, 401 

subcoracoid, 401 

subspinous, 402 
of inferior angle of scapula, 400 
of jaw, 396 
of knee, 417 

of metacarpal bones, 410 
of metatarsal bones, 421 
old, 394, 421 
partial, 393 
of patella, 416 
pathological, 423 
of pelvis, 398 
of phalanges of toes, 421 
of proximal phalanx of 

thumb, 411 
recent, 394 
reduction of, 394 
of ribs, 398 
of scapula, 400 
of semilunar cartilages, 418 
of shoulder, 401 
simple, 393 
spontaneous, 423 
of sternum, 398 
of tarsal bones, 419 



586 



INDEX. 



Dislocation of upper end of ulna, 
408 
of vertebrae, 396 
of wrist, 409 
Dorsal dislocation of femur, 412 
Dorsalis pedis artery, ligation of, 

455 
Dorso-axillary cravat, 35 

-bisaxillary cravat, compound, 

. 36 
Dressing, antiseptic, improvised, 

143 

aseptic, improvised, 143 

cold water, 177 

gauze, 1 39 

moss, 142 

sawdust, 142 

sterilized, 145 
Drainage-tubes, 136 
Dry cupping, 190 

sterilized dressings, 145 
Dupuytren's amputation at the 
shoulder, 486 

splint, 384 



ELASTIC ligature, 279 
Elbow, amputation at, 480 
dislocations of, 405 
figure-of-eight bandage of, 

63 
-joint, excision of, 520 
Electrolysis, 220 
Elliptical amputation, 462 
Enemata, 228 

nutritious, 228 
Epiphyseal fracture, 322 

of radius, 363 
Epistaxis, treatment of, 300 
Erichsen's ligature, 278 
Esmarch's bandage and tube, 287 
Estlander's operation of chest, 

526 
Ether, 233 

administration of, 234 
first insensibility from, 235 
inhaler, 234 
vomiting after, 237 
Ethyl bromide, 241 

chloride, 227 
Excision or excisions, 516 



Excision of ankle-joint, 532 

of astragalus, 533 

of coccyx, 534 

of elbow-joint, 520 

of hip-joint, 528 
anterior, 529 

of inferior maxilla, 536 

instruments for, 517, 518 

of inter-pbalangeal joints, 524 

of knee-joint, 530 

metacarpophalangeal joints, 
524 

of os calcis, 533 

of patella, 531 

of scapula, 527 

of shoulder-joint, 519 

of superior maxilla, 535 

of wrist, 522 
Exploring-needle, 216 

-trocar, 217 
Extensor longus digitorum, tenot- 
omy of, 549 

proprius pollicis, tenotomy of, 
549 
External carotid artery, ligation 
of, 433 

iliac artery, ligation of, 447 
External popliteal nerve, excision 

of, 546 
Eye, crossed bandage of, 52 

crossed bandage of both, 53 
Facial artery, ligation of, 435 

nerve, excision of, 544 



FABADIZATION, 222 
Fascia, strains of, 317 
Felt splints, 328 

Femoral artery, ligation of, 449 
Femur, dislocation of, 412 

anomalous, 415 

dorsal, 412 

ischiatic 412 

pubic, 415 

thyroid, 413 

upper extremity of, 366 
fracture of, 366 

condyles of, 374 

green-stick, 373 

incomplete, 373 

neck of, 366 



INDEX 



587 



Femur, fracture of lower end of, 374 
shaft of, 370 

in children, 372 
osteotomy of, 578 
Fomentations, hot, 173 
Fibula, dislocations of, 418 
fracture of, 382 

of lower end of, 383 
Pott's fracture of, 383 
resection of, 531 
Figure-of-eight bandage, 23 
of chest, 76 
of elbow, 63 
of knee, 85 
of leg, 91 

of neck and axilla, 67 
Fingers, amputation of, 473 
dislocation of, 410 
phalanges, fractures of, 365 
spiral bandage of, 57 
Fixed dressings, 100 
Flap amputations, 460 
Flannel bandage, 98 
Flat knot, 257 
Flaxseed poultice, 171 
Flexible catheter, 245 
Flexor longus digitorum, tenotomy 
of, 549 
pollicis, tenotomy of, 549 
Foot, American bandage of, 88 
amputation of, 489 
Chopart's, 495 
Hey's, 495 
Lisfranc's, 494 
Tripier's, 501 
French bandage of, 89 
spica bandage of, 87 
Forearm, amputation of, 479 
dislocation of, at elbow, 405 
fracture of both bones of, 358 
Forced respiration, 207 
Forceps, haemostatic, in hemor- 
rhage, 286 
Fracture or fractures, 318 
of astragalus, 385 
bandages in, 330 
-bed, 327 

of bones of forearm, 358 
of leg, 377 
-box, 329 
of calcaneum, 384 



Fracture of carpal bones, 363 
of clavicle, 343 
closed, 319 
of coccyx, 340 
Oolles', 361 
comminuted, 319 
complete, 318 
complicated, 320 
compound, 319 

dressing of, 387 
compresses in, 330 
coronoid process of ulna, 358 
of costal cartilages, 339 
deformity in, 322 
direction of, 321 
epiphyseal, 322 
evaporating lotions in, 330 
examination of, 323 
of the femur, 366 
of the fibula, 382 
green-stick, 318 

of bones of forearm, 358 
of head and neck of radius, 358 
of the humerus, 350 
of hyoid bone, 337 
impacted, 320 
incomplete, 318 
of larynx, 337 
of the leg, ambulant method 

in, 380 
longitudinal 321 
of lower end of femur, 374 
of fibula, 383 

maxilla, 334 

end of radius, 360 
of malar bone, 333 
of metacarpal bones, 364 
of metatarsal bones, 386 
multiple, 319 
of nasal bones, 331 
of neck of femur, 366 
oblique, 321 
of olecranon process of ulna, 

356 
open, 319 

dressing of, 387 
partial, 318 
of patella, 375 
of pelvis, 340 
of phalanges of fingers, 365 

of toes, 386 



588 



INDEX. 



Fracture, plaster-of-Paris splints in, 
329 

provisional dressing of, 324 

of radius, epiphyseal, 363 

repair of, 322 

of ribs, 338 

of sacrum, 340 

of scapula, 349 

setting of, 326 

of shaft of femur, 370 

in children, 372 

simple, 319 

of skull, 342 

splints for, 327 

of sternum, 339 

of tarsal bones, 384 

of tibia and fibula, 377 

of trachea, 337 

of upper extremity of femur, 
~366 
maxilla, 333 

varieties of, 318 

of vertebrae, 341 

of zygoma, 333 
Franklinization, 222 
French bandage of foot, 89 
Frontal sinus, trephining of, 540 



GALVANO-CAUTERY, 221 
Gastrostomy, 576 
sutures in, 273 
Gauze, bichloride of mercury, 140 
borated, 142 
carbolized, 141 
cyanide of mercury and zinc, 

141 
dressings, 139 

preparation of, 139 
iodoform, 140 
pads, 133 
pledgets, 133 
pyoktanin, 142 
salicylated, 142 
Gauntlet bandage, 58 
Gely's suture, 268 
Gibson's bandage, 44 
Glover's suture, 261 
Glue and zinc bandage, 116 
Gluteal artery, ligation of, 448 
Gluteo-femoral triangle, 38 



Gluteo-inguinal cravat, 38 
Glycerin enema, 228 
Granny knot, 258 
Green-stick fracture, 318 

of bones of forearm, 358 

of femur, 373 
Gritti's amputation at knee-joint, 

507 
Groin, spica bandage of, double, 83 

single, 80, 81 
Gum and chalk bandage, 114 
Gunshot-wounds, 311 
Guthrie's amputation at hip-joint, 

512 
Gutta-percha splints, 328 



HALL'S method of artificial res- 
piration, 207 
Halstead's quilt suture, 268 
Hamstring tendons, tenotomy of, 

549 
Hancock's amputation at ankle- 
joint, 500 
Hand, amputation of, 473 

carpo-metacarpal, 477 
disinfection of, 147 
Handkerchief bandages, 29 

Barton's, 40 
Harelip suture, 262 
Haemostatic forceps, 286 
Hatter's felt splints, 118 
Head and neck bandage, 51 
four-tailed bandage of, 28 
oblique bandage of, 55 
of radius, dislocation of, 407 
recurrent bandage of, 47 
transverse recurrent bandage 

of, 49 
V-bandage of, 50 
Heat as a sterilizer, 124 
Hemorrhage in amputations, con- 
trol of, 469 
arterial, 281 

acupressure in, 294 
arteriversion in, 292 
cauterization in, 291 
cold in, 289 
control of, permanent, 288 

temporary, 281 
compresses in, 282 



INDEX. 



589 



Hemorrhage, arterial, constriction 
of arteries in, 292 
digital compression in, 281 
Esmarch's tube in, 284 
haemostatic forceps in, 286 
hot water in, 289 
ligation in, 293 
position in, 289 
pressure in, 290 
Spanish windlass in, 283 
styptics in, 289 
torsion in, 291 
tourniquets in, 282 
from bladder, treatment of, 303 
capillary, treatment of, 298 
from middle meningeal artery, 

trephining for, 539 
from the rectum, treatment of, 

303 
secondary, treatment of, 298 
treatment of, 280 
from the urethra, treatment of, 

302 
venous, treatment of, 297 
Hernia, femoral, truss for, 243 
inguinal, truss for, 242 
irreducible, truss for, 245 
umbilical, truss for, 244 
Hey's amputation of foot, 495 
Hip, dislocations of, 412 

-joint, amputation at, 510 
Guthrie's, 510 
Wyeth's, 513 
excision of, 528 
anterior, 529 
Hoey's clamp, 285 
Hot compresses, 173 
fomentations, 173 
water in arterial hemorrhage, 
289 
as a rubefacient, 178 
Humerus, dislocation of head of, 
401 
fracture of, 350 
resection of, 520 
subclavicular dislocation of, 

402 
subcoracoid dislocation of, 401 
subglenoid dislocation of, 401 
subspinous dislocation of, 402 
Hydrogen peroxide, 129 



Hyoid bone, dislocationof, 397 

fracture of, 337 
Hypodermic injections, 214 



TCE-BAG, 177 
1 Immediate irrigation, 174 
Impacted fracture, 320 
Improvised antiseptic dressings, 1 43 

aseptic dressings, 143 
Incised wounds, 307 
Incomplete fracture, 318 

of femur, 373 
India-rubber suture, 263 
Indirect transfusion of blood, 1 97 
Inferior dental nerve, excision of, 
543 

thyroid artery, ligation of, 430 
Infiltration anaesthesia, 231 
Inguinal colostomy, 572 

colotomy, 572 
Injections, hypodermic, 204 

urethral, 253 
Innominate artery, ligation of, 427 
Instruments, sterilization of, 148 
Internal carotid artery, ligation of, 

. . 433 

iliac artery, ligation of, 447 

mammary artery, ligation of. 

430 
popliteal nerve, excision of, 

546 
pubic artery, ligation of, 449 
Interosseous artery, ligation of, 

444 
Inter-pharyngeal joints, excision 

of, 524 
Interrupted plaster-of-Paris dress- 
ing, 104 
suture, 259 
Intestinal anastomosis, sutures in, 

271 
Intravenous injection of milk, 200 

of saline solution, 199 
Intubation of larynx, 564 
instruments for, 565 
operation of, 566 
Iodoform, 127 

collodion, 127 
emulsion, 127 
gauze, 140 



26 



590 



INDEX. 



Iodol, 131 
Irrigation, 174 

immediate, 174 

mediate, 176 
Ischiatic dislocation of femur, 412 
Isinglass plaster, 165 
Issues, 183 

JACKET, plaster-of-Paris, 105 
Jaw, dislocation of, 396 

lower, excision of, 536 
fracture of ? 334 
oblique bandage of, 46 
upper, excision of, 535 
fracture of, 333 
Jobert's suture, 270 
Joints, strapping of, 170 
Junk bags, 329 
Jury-mast with plaster-of-Paris 

jacket, 108 
Jute, 161 



KIDNEY, operations on, 570 
Knee, dislocation of, 417 
figure-of-eight bandage of, 
: 85, 86 

-joint, amputation at, 505 
Carden's, 506 
Gritti's, 507 
arthrectomy of, 531 
excision of, 530 
Knives, amputating, 464 
Knock-knee, osteotomy for, 578 
Kreolin, 129 



T ABOKDE'S method of artificial 
Jj respiration, 207 
Lacerated wounds, 308 
Larrey's amputation at the shoul- 
der-joint, 485 
Laryngo- tracheotomy, 563 
Laryngotomy, 562 
Larynx, fracture of, 337 

intubation of, 564 
Leather splints, 116, 328 
Leeching, 191 
Leeches, 191 
Leg, amputation of, 501 



Leg, figure-of-eight bandage of, 91 

fractures of, 377 
Lembert's suture, 267 
Liebreich's bandage, 96 
Ligation of abdominal aorta, 444 
of anterior tibial artery, 453 
of arteries, 424 
of axillary artery, 431 
of brachial artery, 438 
of common carotid artery, 431 

iliac artery, 445 
of dorsalis pedis artery, 455 
of external carotid artery, 433 

iliac artery, 447 
of the facial artery, 435 
of femoral artery, 449 
of gluteal artery, 448 
of inferior thyroid artery, 430 
of innominate artery, 427 
of internal carotid artery, 433 

iliac artery, 447 

mammary artery, 430 

pudic artery, 449 
of interosseous artery, 444 
of lingual artery, 434 
of occipital artery, 435 
of popliteal artery, 452 
of posterior tibial artery, 456 
of radial artery, 440 
of sciatic artery, 449 
of subclavian artery, 428 
of superior thyroid artery, 434 
of temporal artery, 436 
of ulnar artery, 442 
of vertebral artery, 430 
in arterial hemorrhage, 293 
Ligature, elastic, 279 
securing of, 257 
in vascular growths, 274 

double, 275 

Erichsen's, 278 

quadruple, 276 

single, 275 

subcutaneous, 277 
Lingual artery, ligation of, 434 

nerve, excision of, 543 
Lint, 158 
Lisfranc's amputation of foot, 494 

at the shoulder-joint, 487 
Lister's aorta-compressor, 285 
Lithotomy bandage, 95 



INDEX. 



591 



Lithotomy, lateral, 572 
Local anaesthesia, 229 
Longitudinal fracture, 321 
Lower jaw, fracture of, 334 
Lumbar colostomy, 571 
colotomy, 571 
nephrectomy, 570 



MACKINTOSH, 138 
Malar bone, fracture of, 333 
Many-tailed bandage, 28 
Massage, 224 

Maxilla, inferior, excision of, 536 
lower, fracture of, 334 
superior, excision of, 535 
upper, fracture of, 333 
Mechanical leech, 192 
Mediate irrigation, 176 
Median nerve, excision of, 545 
Mento vertico-oceipital cravat, 32 
Mercury, bichloride, 125 
Metacarpal bones, amputation of, 
476 
dislocation of, 410 
fracture of, 364 
resection of, 524 
Metacarpophalangeal joints, ex- 
cision of, 524 
Metallic cathether, 245 
Metatarsal bones, amputation of, 
491 
dislocation of, 421 
fracture of, 386 
resection of, 534 
Milk, intravenous injection of, 200 
Minor surgery, 119 
Modified circular amputation, 463 
Moist dressings in wounds, 146 
method of dressing wounds, 154 
sterilized dressings, 145 
Moss- dressing, 142 
Moulded plaster-of-Paris splints, 

110 
Mouth-to-mouth inflation, 202 
Moxa, 184 

Multiple fracture, 319 
Muscle -grafting, 220 
Muscles, strains of, 317 
Musculo-spiral nerve, excision of, 
546 



Muslin, oiled, 161 
Mustard foot-bath, 179 

papers, 180 

plaster, 179 

as rubefacient, 179 



NASAL bones, fracture of, 331 
Neck and axilla, figure-of- 
eight bandage of, 67 
Needles, acupuncture, 183 
aneurism, 293 
exploring-, 216 
-holder, 256 
mounted, 256 
surgical, 255 
Nephrectomy, abdominal, 570 

lumbar, 570 
Nephrorrhaphy, 570 
Nephrotomy, 570 

Nerve, anterior crural, excision of, 
546 
external popliteal, excision of, 

546 
facial, excision of, 544 
-grafting, 220, 541 _ _ 
inferior dental, excision of, 543 
internal popliteal, excision of, 

546 
lingual, excision of, 543 
median, excision of, 545 
musculo-spiral, excision of, 

546 ^ 
operations upon, 540 
radial, excision of, 545 
sciatic, excision of, 546 
spinal accessor excision of, 

545 
-stretching, 540 
superior maxillary, excision of, 

543 
supra-orbital, excision of, 542 
suture of, 541 
ulnar, excision of, 545 
Neurectasy, 540 

of special nerves. See under 
each nerve. 
Neurotomy, 540, 541 
Neuroplasty, 541 
Neurorrhaphy, 541 
Nitrate of silver as rubefacient, 180 



592 



INDEX. 



Nitrous oxide gas, 232 
Normal salt-solution, 199 
Nose, T-bandage of, 27 
Nutritious enemata, 228 



AAKUM, 159 
\J poultice, 173 
Oblique bandage, 20 
of head, 55 
of jaw, 46 

fracture, 321 
Occipital artery, ligation of, 435 
Occipto-facial bandage, 54 

-frontal bandage, 56 
triangle, 32 
(Esophageal bougie, 212 
(Esophagotomy, external, 576 
Oiled muslin, 161 

silk, 161 
Old dislocation, 394, 421 
Olecranon process of ulna, fracture 

of, 356 
Open fracture, 319 

dressing of, 387 
Operation or operations, 424 

antiseptic, 150 

aseptic, 153 

preparation of patient for, 149 
of surgeon for, 148 
Os calcis, excision of, 533 
Osteotomy, 577 

for bowlegs, 579 

of femur, 578 

for knock-knee, 578 
Oval amputation, 462 



PANELECTEOSCOPE, 224 
Paper splints, 329 
Paquelin's cautery as rubefacient, 
180 
thermo-cautery, 187 
Paraffin bandage, 115 

paper, 161 
Parchment paper, 139, 162 
Partial dislocation, 393 

fracture, 318 
Passive motion, 225 
Pasteboard splints, 117 
Patella, dislocations of, 416 



Patella, excision of, 531 

fracture of, 375 
Pathological dislocations, 423 
Pelvis, dislocation of, 498 

fracture of, 340 
Penis, spiral reversed bandage of, 

93 
Periosteal flaps in amputation, 464 
Periosteotome, 467 
Permanganate of potassium, 130 
Peroneal tendons, tenotomy of, 548 
Peroxide of hydrogen, 129 
Petit' s tourniquet, 283 
Phalanges of fingers, dislocation of, 
410 
fractures of, 365 
of toes, dislocation of, 421 
fractures of, 386 
PirogofF's amputation at ankle- 
joint, 498 
Plate suture, 265 
Plaster or plasters, 164 
adhesive, 164 
isinglass, 165 
mustard, 179 
-of-Paris bandage, 101 

application of, 102 
preparation of, 102 
removal of, 112 
dressing, interrupted, 104 

uses of, 113 
jacket, application of, 105 

with jury-mast, 108 
removal of, from hands, 

111 
splints in fracture, 329 
moulded, 110 
resin, 164 

rubber adhesive, 164 
soap, 165 
swan's-down, 164 
poisoned wounds, 310 
Popliteal artery, ligation of, 452 
Porous felt splints, 118 
Position in arterial hemorrhage, 

289 
Posterior tibial artery, ligation of, 
456 
tendon, tenotomy of, 548 
Potassium, permanganate, 130 
Pott's fracture of fibula, 383 



INDEX. 



593 



Poultices, 170 

antiseptic, 173 

bread, 172 

charcoal, 172 

flaxseed, 171 

oakum, 173 

starch, 172 
Powder-burns, 311 
Pressure in arterial hemorrhage, 

290 
Prostatic catheter, 246 
Protective, 138 

Provisional dressing of fracture, 324 
Pubic dislocation of femur, 415 
Puncturation, 189 
Punctured wounds, 310 
Pyoktanin, 130 

gauze, 142 



QUADRUPLE ligature, 276 
Quilled suture, 264 
Quilt suture, 263 



RADIAL artery, ligation of, 440 
nerve, excision of, 545 
Radius, dislocation of head of, 407 
fracture of head and neck of, 
358 
of lower end of, 360 
resection of, 521 
Rapid respiration, anaesthesia from, 

230 
Raw-hide splints, 116 
Recent dislocations, 394 
Rectal bougie, 227 

tube, 227 
Rectum, hemorrhage from, treat- 
ment of, 303 
Recurrent bandage, 24 
of head, 47 
of stump, 94 
Reduction of dislocations, 394 
Reef knot, 257 
Resections, 516 

of clavicle, 525 
of fibula, 531 
of humerus, 520 
instruments for, 517, 518 
of metacarpal bones, 524 



Resections of metatarsal bones, 534 

of radius, 521 

of ribs, 526 

of sternum, 527 

of tibia, 531 

of ulna, 521 
Respiration, artificial, 201 

forced, 207 

rapid, anaesthesia from, 230 
Resin plaster, 164 
Retractors, 163 
Ribs, dislocation of, 398 

fracture of, 338 

resection of, 526 
Roller bandage, 14 
double, 16 
single, 16 
Roux's amputation at ankle-joint, 

500 
Rubber adhesive plaster, 164 

bandage, 98 

dam, 139 

tissue, 139, 161 
Rubefacients, 178 



SACRUM, fracture of, 340 
Salicylated gauze, 142 
Saline solution, intravenous injec- 
tion of, 199 
Salt-solution, normal, 199 
Sand-bags, 329^ 
Saws, amputating, 465 

Butcher's, 517 
Sawdust dressing, 142 
Scalds, 312 
Scapula, dislocation of, 400 

dislocation of inferior angle of, 

400 
excision of, 527 
fracture of, 349 
Scarification, 188 
Sciatic artery, ligation of, 449 

nerve, excision of, 546 
Scultetus, bandage of, 97 
Secondary hemorrhage, treatment 
of, 298 
sutures, 255 
Semilunar cartilages, dislocation of, 
418 



sepsis 



119 



26* 



594 



INDEX. 



Septic wounds, dressing of, 157 
Serum, injections of, 215 
Seton, 184 

needle, 185 
Shotted suture, 265 
Shoulder, dislocation of, 401 

-joint, amputation above, 488 
at, 484 

Dupuytren's, 486 
Larre>'s, 485 
Lisfranc's, 487 
Spence's, 487 
excision of, 519 
spica bandage of, ascending, 64 
descending, 66 
Signorini's tourniquet, 285 
Silicate of potassium bandage, 115 

of sodium bandage, 115 
Silk, oiled, 161 

sterilization of, 134 
Silkworm-gut, 134 
Simple dislocation, 393 

fracture, 319 
Sinapisms, 179 
Sinus, 307 
Skin-grafting, 217 

Thiersch's method, 218 
Skull, fracture of, 342 
trephining of, 538 
Slings, 28 
Soap plaster, 165 
Sounds, 249 
Spanish windlass, 283 
Spence's amputation at shoulder- 
joint, 487 
Spica bandage, 22 

of buttock, 84 

of foot, 87 

of groin, double, 83 

of groin, single, 80, 81 

of shoulder, ascending, 64 

descending, 66 
of thumb, 61 
Spinal accessory nerve, excision of, 

545 
Spiral bandage, 20 
of chest, 75 
of finger, 57 
reversed bandage, 21 

of lower extremity, 90 
of penis, 93 



Spiral reversed bandage of upper 

extremity, 62 
Spirits of turpentine, 178 
Splints, 327 

binder's board, 117, 328 

Dupuytren's, 384 

felt, 328 

gutta-percha, 328 

hatter's felt, 118 

leather, 116, 328 

paper, 329 

pasteboard, 117 

porous felt, 118 

raw-hide, 116 
Sponges, sterilization of, .1 32 
Spontaneous dislocations, 423 
Sprains, 315 

fracture, 317 
Staffordshire knot, 259 
Staphylococcus pyogenes albus, 
121 

aureus, 121 

citreus, 121 
Starched bandage, 114 
Starch poultice, 172 
Sterilization of catgut, 135 

by heat, 124 

of instruments, 148 

of silk, 134 

of sponges, 132 
Sterilized dressings, dry, 145 

moist, 145 
Sterno-cleido-mastoid, tenotomy of, 

550 
Sternum, dislocation of, 398 

fracture of, 339 

resection of, 527 
Stomach pump, 211 

tube, 210 
Strains of muscles and fascia, 317 
Strapping, 165 

breast, 167 

of carbuncle, 170 

chest, 167 

of joints, 170 

testicle, 166 

of ulcers, 168 
Streptococcus pyogenes, 121 
Stump, recurrent bandage of, 94 
Styptics in arterial hemorrhage, 
289 



INDEX. 



595 



Subastragaloid amputation, 497 
Subclavian artery, ligation of, 428 
Subclavicular dislocation of hu- 
merus, 402 
Subcoracoid dislocation of humerus, 

401 
Subcutaneous ligature, 277 
Subcuticular suture, 262 
Subglenoid dislocation of humerus, 

401 
Subspinous dislocation of humerus, 

402 
Sulpho-carbolate of zinc, 128 
Superior maxillary nerve, excision 
of, 543 

thyroid artery, ligation of, 434 
Supra-orbital nerve, excision of, 
542 

pubic lithotomy, 573 
Surface thermometer, 226 
Surgeon's knot, 258 

preparation for operation, 148 
Surgery, minor, 119 
Surgical cleanliness, 122 

needles, 255 
Suspensory bandage of breast, 37 

and compressor bandage of 
breast, 78 
Sutures, 254 

of approximation, 255 

Bouisson's, 269 

buried, 260 

button, 264 

of coaptation, 255 

continued, 261 

Czerny, 270 

in gastrostomv, 273 

Gely's, 268 

Glover's, 261 

Halstead's, 268 

harelip, 262 

India-rubber, 263 

interrupted, 259 

in intestinal anastomosis, 271 

Jobert's, 270 

of nerves, 541 

plate, 265 

quilled, 264 

quilt, 263 

of relaxation, 255 

removal of, 266 



Sutures, subcuticular, 262 

secondary, 255 

securing of, 257 

shotted, 265 

of tendons, 550 

tongue and groove, 265 

twisted, 262 

varieties of, 259 
Sylvester's method of artificial res- 
piration, 205 
Sy rue's amputation at ankle-joint, 
497 



TAMPOX, 162 
Tarsal bones, dislocation of, 
419 
fracture of, 384 
Tarso-metatarsal amputations, 493 
T-bandages, 24 
of chest, 25 
double, 26 
of nose, 27 
single, 24 
Teale's amputation, 463 
Temporal artery, ligation of, 436 
Tenaculum, 293 

Tendo Achillis, tenotomy of, 547 
Tendons, lengthening of, 552 
operations upon, 547 
suture of, 550 

secondary, 551 
Tenotomes, 547 
Tenotomy, 547 

of adductor longus, 549 

of anterior tibial tendon, 548 

of extensor proprius pollicis, 

549 
of flexor longus digitorum, 

549 
of flexor longus pollicis, 549 
of hamstring tendons, 549 
of peroneal tendons, 548 
of posterior tibial tendon, 548 
of sterno-cleido-mastoid, 550 
of tendo Achillis, 547 
Tent, 162 
Testicle, removal of, 575 

strapping of, 166 
Thiersch's method of skin-grafting, 
218 



596 



INDEX. 



Thigh, amputation of, 507 
Thumb, dislocation of proximal 
phalanx of, 411 

spica bandage of, 61 
Thyroid dislocation of femur, 

413 
Tibia, fracture of, 377 

resection of, 531 
Toes, amputation of, 489 

fracture of phalanges of, 386 
Tongue and groove suture, 265 
Torsion in arterial hemorrhage, 

291 
Tourniquets, 283, 285 

abdominal, 510 

in amputation, 469 

Petit's^ 283 

Signorini's, 285 
Trachea, fracture of, 337 
Tracheal dilators, 554 

forceps, 555 
Tracheotomy, 553 

after-treatment of, 561 

anaesthetics in, 557 

for foreign bodies, 562 

operation of, 557 

position of patient for, 556 

tube, 556 
Transfusion of blood, 195 

arterial, 199 

of blood, direct, 196 
indirect, 197 
Transverse fracture, 321 

recurrent bandage of head, 49 
Trapping plaster-of- Paris bandage, 

110 
Trephining the antrum of High 
more, 540 

of frontal sinus, 540 

for hemorrhage from middle 
meningeal artery, 539 
m the skull, 538 
Tripier's amputation of foot, 501 
Trusses, 241 

for femoral hernia, 243 

for inguinal hernia, 242 

for irreducible hernia, 245 

for umbilical hernia, 244 
Tuberculous abscess, 305 
Turpentine stupes, 178 
Twisted suture, 262 



ULCEKS, strapping of, 168 
Ulna, dislocation of upper end 
of, 408 
fracture of coronoid pro- 
cess of, 358 
of olecranon process 
of, 356 
resection of, 521 
Ulnar artery, ligation of, 442 

nerve, excision of, 545 
Upper extremity, spiral reversed 
bandage of, 62 
jaw, fracture of, 333 
Urethra, hemorrhage from, treat- 
ment of, 302 
Urethral injections, 253 
Urethroscope, 223 



yACCINATION, 212 

V Varicocele, operation for, 575 
Vascular growths, ligatures in ; 274 
V-bandage of head, 50 
Velpeau's bandage, 68 
Venesection, 193 
Venous hemorrhage, treatment of, 

297 
Vertebrae, dislocations of, 395 

fracture of, 341 
Vertebral artery, ligation of, 430 
Vesicants, 181 
Vomiting after ether, 237 



WAXED paper, 161 
Wet cupping, 191 
Wood-wool, 161 
Wounded arteries, treatment of, 

299 
Wounds, asepsis in, method of se- 
curing, 145 
chemical sterilization in, 146 
contused, 309 
dressing of, 307 
dry dressings in, 145 
gunshot, 311 
incised, 307 
lacerated, 308 

moist dressings in, 146, 154 
poisoned, 310 
punctured, 310 



INDEX. 



597 



Wounds, reapplication of dressings 

in. 154 
Wrist, amputation at, 478 
dislocations of, 409 
excision of, 522 
Wveth's amputation at hip-joint, 
513 



Wyeth's pins in amputation at hip- 
joint, 513 
at shoulder-joint, 485 

ZIXC chloride, 128 
sulpho-carbolate, 1^8 
Zygoma, fracture of, 333 



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